Client Registration Form

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Client Registration Form

Please complete the form below. Some steps are Skipped Depending on the selections that are made.

Step 1 of 7

Name

First

Last

Mobile Phone

Date Of Birth (DD/MM/YYYY)

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Medical Centre

Medical Centre you regularly attend

General Practitioner

Specialist

Medicare Number

Medicare ID

The number next to the clients name.

Private Health Insurer

Condition Type

Emergency Contact

Next of Kin Partner etc

Where did you hear about us

What are we treating?

Injury, Body area. Etc

Enhanced Primary Care Plans

What is Enhance Primary Care Referral?

Enhanced Primary Care (EPC) for Allied Health Services is a medicare rebate system to help refund part of the cost of attending a private allied health service. These include general practitioners, nurse practitioners, midwives, practise nurses and allied health providers. Please see the below links for more information.

What is the process?

If you have a diagnosed chronic or terminal medical condition, you may be entitled to a limited number of Medicare-subsidised allied health services, i.e., physiotherapy, dietitian, and podiatry.

To access these services, Medicare has strict criteria that must be met.

You must have a chronic medical condition that meets the Medicare definition.

A chronic medical condition is one that has been or is likely to be present for at least six months, including but not limited to:

asthma.
cancer.
cardiovascular illness.
diabetes mellitus.
mental health conditions (including dementia).
musculoskeletal conditions; and
stroke; or
terminal illness.

You must also require the services of two other health providers (apart from your doctor). You will first need to ask your doctor if you are eligible and if so, what services you may access. If you are eligible, you will be asked to make an appointment with our nurse to draw up the paperwork for the management plan and the team care paperwork to access allied health services. This will take between 30 and 45 minutes. You will also need a follow-up appointment with your doctor to complete the plans. Once this process is complete, you can access the eligible services.

Under management plans, you may be eligible for up to 5 visits per calendar year. This is spread among all allied health professions. This comes off the tally if you see another allied health professional under the plan. We ask upfront if the appointments have been used elsewhere, but sometimes, this can result in the plan being overserviced. This will result in the payment by the client to cover the cost of the appointment, which is $60.35. With all GP management plans, a $25 fee is applicable to every appointment under the plan. If you have any further questions, please refer to Sarah, our practice manager.

Informed Consent

Physiotherapy treatment and other therapies including dietetics, exercise physiology and speech pathology are generally an effective and safe form of treatment however like any treatment there are benefits and risks. The purpose of this form is to let you know what your rights are and how we address the issue of collaborative decision making and informed consent between practitioner and patient.

Practitioners in this practice will discuss your condition and options for treatment with you so that you are appropriately informed and can make decisions relating to your treatment. You may choose to consent to or refuse any form of treatment for any reason, including religious or personal grounds, once you have given consent at any time.

Please read the following and indicate that you have done so by signing your client registration form:

Questions of a Personal Nature

Your practitioner may ask personal questions relating to your injury/health condition and how it impacts on your “activities of daily living”. The more information you provide, the more likely it is that the practitioner can provide an effective treatment/advice. It is your choice as to what information you choose to provide. If you feel uncomfortable with a particular question or group of questions, please let the practitioner know and they will cease treatment immediately.

Physical Contact

During the examination, assessment and treatment it may be necessary for your practitioner to make physical contact. Your practitioner will ask your permission before making physical contact with you in any way. Where ever possible, towels will be used for screening. Physical contact requires your express consent. You may withdraw consent at any time at which point all physical contact will cease immediately. Please inform your practitioner if you feel uncomfortable at any time.

Risks Related to Treatment

As with all forms of treatment, there are risks and benefits. The practitioner will discuss any foreseeable risks with you prior to administering treatment/advice. In some cases, the practitioner may ask you to read information related to a particular treatment and they may request that you sign a further consent form. This is to ensure that you fully understand the risks involved. You may withdraw your consent at any time.

Children and Minors

Consent of a custodial parent is required to treat a minor.

Substituted Consent

Where a person is incapable of understanding the risks and benefits of treatment, consent may be provided by another person legally authorised to provide such consent. Evidence of Legal Authorisation is required in such circumstances.

You need to let us know

The risks related to some treatments can increase if the practitioner is not aware of certain facts about your medical history or other facts. Please inform the practitioner if you have

Do you have (select the ones attributed to you)?

A Pacemaker or Heart Condition
Suffer From Blood Clots Thrombosis or Stroke
Suffer From Diabetes

Are you currently taking any medications?

If so please list.

A cancellation fee of $40 can be applied will be charged for nonattendance or less than 6 hours’ notice for private clients.
Cancellation 24 Hrs Before for NDIS Clients Will Be Charged 90% of the Service Fee.
Workers Compensation Client will be charged the full Schedule for for Failing to to attend the appointment or not giving Sufficient 24hrs Notice.
Appointment reminders for the following day are sent out at 9am the day prior please contact the clinic if you need to reschedule

We do not bulk bill – payment at completion of consultation is appreciated.

We accept Cash, EFTPOS, Credit Card and Hicaps for direct claiming.

If you are being treated under Workers Compensation, please inform reception.

File Upload

Click or drag a file to this area to upload.

Any Other Referrals or Scans you would like saved to your file.

By clicking submit below you acknowledge that you have read and understood the above terms and conditions and viewed the informed consent documentation provided.

I Agree to the above terms and conditions of Soulitude Health.

Yes I Agree

Custom Captcha

What is 7+4?

Signature

Clear Signature

Client Registration Form

Enhanced Primary Care Plans

What is Enhance Primary Care Referral?

What is the process?

By clicking submit below you acknowledge that you have read and understood the above terms and conditions and viewed the informed consent documentation provided.

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