RHP Admission Form TitleMrMrsMissMsMasterDrYour Full Name (Required)Date of birth (Required)Clinic Site Kelvin GroveNathanContact Number (Required) Your EmailStreet Address (Required) Suburb Postcode Occupation Private Health Fund AHMAustralian UnityBUPACBHSDefence HealthFrank HealthGMBHAGUCHHealth.comHBAHBFHCFMedibankMBFNIBPhoenix Health FundPolice HealthQueensland Country Health FundThe Doctors Health FundTranspor HealthTUHWestfundOtherAre you a DVA/HCC/Pension Card Holder? YesNoIf Yes, please enter the card number Your GP’s Name & Practice Do you consent for RHP to contact your GP regarding your condition/progress? YesNoYour Coach’s Name, Telephone and Email address Do you consent for RHP to contact your coach regarding your condition/progress? YesNoHow did you hear about us? (Required) Word of MouthDoctors ReferralYellow PagesWeb SearchRHP WebsiteOtherIf 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 meCancellation Policy Acceptance(Required) I have read, understood and agree to be bound by the terms and conditions of clinic payment and cancellations policyInformed 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 consentNewsletter Invitation Would you like to subscribe to our e-newsletter?YesNo