Title

Your Full Name (Required)

Date of birth (Required)

Clinic Site

Contact Number (Required)

Your Email

Street Address (Required)

Suburb

Postcode

Occupation

Private Health Fund

Are you a DVA/HCC/Pension Card Holder?

If Yes, please enter the card number

Your GP's Name & Practice

Do you consent for RHP to contact your GP regarding your condition/progress?

Your Coach's Name, Telephone and Email address

Do you consent for RHP to contact your coach regarding your condition/progress?

How did you hear about us? (Required)

If Referred by Someone, please state the Name of the Referrer (insert NIL if not referred)(Required)

What are your presenting problems?

What other doctors or healthcare providers have you seen for this condition?

Why is it important to you to address this problem at RHP now?

What two (2) main things do you hope to achieve from today’s session?

By ticking this box you acknowledge that the information you entered is correct & completed by you (parent/guardian if under 18 years of age)(Required)
 I acknowledge that the information I submitted is correct & filled out by me


Cancellation Policy Acceptance(Required)
 I have read, understood and agree to be bound by the terms and conditions of clinic payment and cancellations policy


Informed Consent Acknowledgment(Required)
 I have read & understood the statements relating to consent for treatment. I offer my consent to receive treatment within the practice until such time as I withdraw my consent


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