The Health Psychology Clinic Client Registration Form

Patient Registration Form

PATIENT DETAILS

MrMrsMissMsDr

First Name

Last Name

Preferred Name

Date of Birth

Gender

MaleFemaleOther/prefer not to say

English is a Second Language

YesNo

Ethnicity

ATSI

AboriginalTorres Strait IslanderNone of the Above

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Address

Postcode

City / Suburb

State

EMERGENCY CONTACT DETAILS

Name

Home Phone

Mobile Phone

Work Phone

Best way to contact your emergency contact 1?

Home PhMobile PhWork Ph

EMERGENCY CONTACT 2

Name

Emergency Contact 2 Home Phone

Emergency Contact 2 Mobile Phone

Best way to contact your emergency contact 2?

Home PhMobile PhWork Ph

REFERER DETAILS

Referrer's Name

Referrer's Address

Family Doctor/ Regular General Practitioner Name (if different to referrer)

GP Address (if different to referrer)

I consent to The Health Psychology Clinic communicating with the referrer and my regular GP

PREFERRED PAYMENT METHOD

Pay automatically (payment billed to your nominated credit card after each session)

Pay online (invoice emailed to you after each session with a link to online payment method)

Invoice sent to a 3rd party payer (e.g NDIS plan manager, DVA, Aged care provider, Employer, Insurance company etc).

MEDICARE

If you use a different name or alias please write the your name & surname as it appears on your Medicare card

Name on Medicare Card

Medicare Card No.

Individual Record Number (ie. your number on the card if multiple people are on your card)

Expiry

Medicare Address (if different to your residential address)

NDIS

NDIS Participant Number

Support Coordinator/ Plan Manager Name

Support Coordinator /Plan Manager Organisation

Date of expiry of current NDIS plan

PRIVATE HEALTH INSURANCE

Do you wish to use your private health insurance to claim for this service?

YesNo

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA Card Type

GoldWhiteLilacOrangeBlue

DVA No.

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

Draw signature|Type signatureClear

Today's Date

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