New Patient Form

PERSONAL DETAILS

Title *

First Name *

Middle Name

Last Name *

Prefer to be known as

Gender *

Date of Birth *

Email address *

Occupation

Mobile Number (10 digits and no spaces) *

Home Phone Number

Residential address *

City/Town *

State *

Postcode *

Emergency contact name *

Emergency contact relationship *

Emergency contact number *

How are you going to be coming through the clinic, please select one *

Private patient (With private health insurance or without) Medicare (Using Care Plan from treating GP) *Care Plan from GP required Type 2 Diabetes Referral *GP referral requiredWorkcover Claim *Referral required MVA Claim *Referral requiredDVA (Department of Veterans Affairs) *Referral from GP required NDIS (Claiming services through the NDIS) *Must have current NDIS plan Other (please give more information at next step)

PRIVATE PATIENTS

Do you have private health insurance "EXTRAS"? *

YesNo

If "YES" Name of Fund *

Private Health Membership Number *

CANCELLATION POLICY
The following procedures have been put into place to alleviate the disruption to this clinic and to other patients.

We require notice to the clinic by 9am on the morning of your scheduled appointment otherwise a cancellation fee (50% of normal consultation fee) may be incurred. Please be aware that this fee will not be covered by your private health insurance.

If you are unable to attend your scheduled appointment, the practice will when able, provide you with an alternative appointment time on your scheduled day of service.

We realise that appointments made in advance can be difficult to remember, so to help you from forgetting we do offer SMS reminders the day before your appointment.

Please note the cancellation fee will not be covered by your private health and will need to paid prior to your next appointment to continue treatment..

Patients who either arrive late or miss an entire appointment will be charged the cancellation fee.

Patients arriving late to an appointment but within their time allocation, may receive a shorter consultation in an effort not to inconvenience other patients with scheduled appointments.

*

FAILING TO ATTEND YOUR SCHEDULED APPOINTMENT WILL RESULT IN
1st time - Warning given
2nd time - Being charged 50% of the consultation fee

All fees will need to be paid before any future bookings can be made *

MEDICARE

Medicare Number (10 digits) *

Reference Number (number next to your name) *

Expiry Date (Month) *

Expiry Date (Year) *

CHARGES FOR CARE PLANS
Please be aware we are not a bulk bill clinic and that only a portion of the consult fee is covered by Medicare.
On the day you will be required to pay the full consultation fee on a debit or credit card. We will then process your rebate of $63.40 online and you will then see this back in your bank account within 24 hours.
*

CANCELLATION POLICY
The following procedures have been put into place to alleviate the disruption to this clinic and to other patients.

We require notice to the clinic within 24 hours of your scheduled appointment otherwise a cancellation fee (50% of consultation fee) may be incurred.

We realise that appointments made in advance can be difficult to remember, so to help you from forgetting we do offer SMS reminders two days before your appointment.

Please note the cancellation fee will not be covered by your private health or medicare claim and will need to paid prior to your next appointment to continue treatment..

Patients who either arrive late or miss an entire appointment will be charged the cancellation fee.

Patients arriving late to an appointment but within their time allocation, may receive a shorter consultation in an effort not to inconvenience other patients with scheduled appointments.

*

FAILING TO ATTEND YOUR SCHEDULED APPOINTMENT TIME WILL RESULT IN
1st Time - Warning given
2nd Time - Being charged 50% of the consult fee

All fees will need to be paid before any future bookings can be made.
*

Please bring your medicare card with you to your appointment.

Type 2 Diabetes Referral

Medicare Number (10 digits) *

Reference Number (number next to your name) *

Expiry Date (Month) *

Expiry Date (Year) *

CHARGES FOR CARE PLANS
Please be aware we are not a bulk bill clinic and that only a portion of the consult fee is covered by Medicare.
On the day you will be required to pay the full consultation fee for your initial assessment on a debit or credit card. We will then process your rebate of $81.35 online and you will then see this back in your bank account within 24 hours. Follow up group classes will cost $32 and you will receive a medicare rebate of $20.25 within 24 hours using your T2D referral. *

CANCELLATION POLICY
The following procedures have been put into place to alleviate the disruption to this clinic and to other patients.

We require notice to the clinic within 24 hours of your scheduled appointment otherwise a cancellation fee (50% of consultation fee) may be incurred.

We realise that appointments made in advance can be difficult to remember, so to help you from forgetting we do offer SMS reminders two days before your appointment.

Please note the cancellation fee will not be covered by your private health or medicare claim and will need to paid prior to your next appointment to continue treatment..

Patients who either arrive late or miss an entire appointment will be charged the cancellation fee.

Patients arriving late to an appointment but within their time allocation, may receive a shorter consultation in an effort not to inconvenience other patients with scheduled appointments.

*

FAILING TO ATTEND YOUR SCHEDULED APPOINTMENT TIME WILL RESULT IN
1st Time - Warning given
2nd Time - Being charged 50% of the consult fee

All fees will need to be paid before any future bookings can be made. *

Please bring your medicare card with you to your appointment.

WORKCOVER

Employers Name *

Employers Contact Name *

Employers Contact Phone Number *

Date of injury *

Injury *

Employers Insurance Agent *

EML Gallagher BassettOther

If selected "Other" please state *

Workcover Claim number *

Workcover Case Manager's Full Name *

Workcover Case Manager's Contact Number *

Workcover Case Manager's Email Address *

CANCELLATION POLICY
The following procedures have been put into place to alleviate the disruption to this clinic and to other patients.

We require notice to the clinic within 24 hours of your scheduled appointment otherwise a cancellation fee (50% of consultation fee) may be incurred.

We realise that appointments made in advance can be difficult to remember, so to help you from forgetting we do offer SMS reminders two days before your appointment.

Please note the cancellation fee will not be covered by your private health or medicare claim and will need to paid prior to your next appointment to continue treatment..

Patients who either arrive late or miss an entire appointment will be charged the cancellation fee.

Patients arriving late to an appointment but within their time allocation, may receive a shorter consultation in an effort not to inconvenience other patients with scheduled appointments.

*

FAILING TO ATTEND YOUR SCHEDULED APPOINTMENT WILL RESULT IN

1st Time - Warning given
2nd Time - Being charged 50% of the consult fee

All fees will need to be paid before any future bookings can be made.

*

Please remember to bring a copy of your referral and any other supporting documentation to your appointment.

MOTOR VEHICLE ACCIDENT CLAIMS

Date of accident *

Claim number MVA *

If Selected "Other" for insurance company please state *

MVA Case Manager's Name *

MVA Case Manager's Contact Number *

MVA Case Manager's Email Address *

CANCELLATION POLICY
The following procedures have been put into place to alleviate the disruption to this clinic and to other patients.

We require notice to the clinic within 24 hours of your scheduled appointment otherwise a cancellation fee (50% of consultation fee) may be incurred.

We realise that appointments made in advance can be difficult to remember, so to help you from forgetting we do offer SMS reminders two days before your appointment.

Please note the cancellation fee will not be covered by your private health or medicare claim and will need to paid prior to your next appointment to continue treatment..

Patients who either arrive late or miss an entire appointment will be charged the cancellation fee.

Patients arriving late to an appointment but within their time allocation, may receive a shorter consultation in an effort not to inconvenience other patients with scheduled appointments.

*

FAILING TO ATTEND YOUR SCHEDULED APPOINTMENT WILL RESULT IN

1st Time - Warning given
2nd Time - Being charged 50% of the consult fee

All fees will need to be paid before any future bookings can be made.

*

Please remember to bring a copy of your referral and any other supporting documentation to your appointment.

DEPARTMENT OF VETERANS AFFAIRS

DVA number *

DVA health care card *

White card Gold cardTPI card

DVA Specific Conditions Approved *

CANCELLATION POLICY
The following procedures have been put into place to alleviate the disruption to this clinic and to other patients.

We require notice to the clinic within 24 hours of your scheduled appointment otherwise a cancellation fee (50% of consultation fee) may be incurred.

We realise that appointments made in advance can be difficult to remember, so to help you from forgetting we do offer SMS reminders two days before your appointment.

We also understand that at times unforeseen circumstances and situations can arise which may impact you being able to attend your appointment in person. To help with this and to avoid the cancellation fee we can charge the appointment to a telehealth appointment. This involves the Exercise Physiologist conducting the appointment over the phone.

Please note the cancellation fee will not be covered by DVA and will need to be paid prior to your next appointment to continue treatment.

Patients arriving late to an appointment but within their time allocation, may receive a shorter consultation in an effort not to inconvenience other patients with scheduled appointments.

*

FAILING TO ATTEND YOUR SCHEDULED APPOINTMENT WILL RESULT IN

1st Time - Warning given
2nd Time - Being charged 50% of the consult fee

All fees will need to be paid before any future bookings can be made.

*

Please remember to bring a copy of your referral and your DVA card to your appointment.

NDIS

Will you be claiming these services from NDIS? *

YesNo

NDIS number: *

Plan Start Date *

Plan End Date *

Are you Plan Managed or Self Managed? (Please note we do not see NDIA managed plans)

Plan ManagedSelf Managed

Name of Plan management company that pays for accounts *

Email address of plan management company that account invoices need to be sent to *

What section of your NDIS Plan is your funds allocated from? *

Improved Daily Living (IDL)Improved Health and Wellbeing (IHW)Early Childhood Supports (ECI)

Do you consent for Move Exercise Physiology to provide a copy of your signed service agreement with your NDIS plan managers for funding allocation purposes? *

YesNo

Please upload a copy of your current NDIS plan goals here

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Please note we do not need a copy of your entire NDIS plan and you have the right to choose what sections and who you share your plan with. More details can be found here https://www.ndis.gov.au/participants/using-your-plan/managing-your-plan/sharing-your-plan#:~:text=Your%20NDIS%20plan%20is%20yours,a%20doctor%20or%20family%20member.

CANCELLATION POLICY
We require notice to the clinic within 24 hours of your scheduled appointment otherwise a cancellation fee may be incurred. Failure to contact the clinic will result in 100% of the normal consultation fee being charged.

We realise that appointments made in advance can be difficult to remember, so to help you from forgetting we do offer SMS reminders two days before your appointment.

We also understand that at times unforeseen circumstances and situations can arise which may impact you being able to attend your appointment in person. To help with this and to avoid the cancellation fee we can change the appointment to a telehealth appointment. This involves the Exercise Physiologist conducting the appointment over the phone. If you are still unable to attend your scheduled appointment, the practice will when able, provide you with an alternative appointment time on your scheduled day of service.

Patients arriving late to an appointment but within their time slot, may receive a shorter consultation in an effort not to inconvenience other clients who may be waiting. This will be charged at the rate of the scheduled appointment booked. *

FAILING TO ATTEND YOUR SCHEDULED APPOINTMENT WILL RESULT IN

Being charged 100% of the consult fee

All fees will need to be paid before any future bookings can be made.

*

To help up get to know you or your child better, we would apprecitae if you could complete the following. This will help our Exercise Physiologists better understand what you or your child likes, dislikes and any triggers or strategies we can use to maximise our results and build a trusting relationship.

NDIS related condition to be treated *

If you selected "Other" above, please state

What do you or your child enjoy? *

What are some of your or your child's dislikes? *

Please list Triggers for behaviour and parent/practitioner strategies For example: I feel anxious when i don't know what to expect / I like it when you tell me what will be happening next with visuals/pictures *

OTHER INFORMATION

Primary condition to be treated *

Name of clinic of General practitioner in which you attend *

Name of usual General Practitioner *

Do you have any known allergies? *

YesNo

What are your known allergies? *

If you have any other documentation that is relevant to your conditions please upload these below or bring them with you to your scheduled appointment. This will help with our Exercise Physiologists assessment and understanding.

Please upload any relevant documentation or referrals here

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TO ALL CLIENTS, PLEASE READ CAREFULLY AND SIGN BELOW

Client Disclaimer

I give consent for Move Exercise Physiology to record and store notes, medical information or other pertinent information related to services received.

Move Exercise Physiology’s privacy policy complies with all Commonwealth, State and local privacy laws. This privacy policy can be viewed on request.

I authorise Move Exercise Physiology to release any medical information, verbally or in writing, as is necessary to my employer, their work cover agent, Employers Mutual, Gallagher Bassett, my solicitor, my general practitioner, other allied health providers, specialists or case managers relevant to the management of my chronic condition/s. I understand that Move Exercise Physiology does not accept responsibility for lost, stolen or damaged valuables, cash or personal items.

I acknowledge and agree that:

I am aware that the facilities and services offered by Move Exercise Physiology involve risk, included but not limited to, risk of bodily injury;

I have and will provide all the relevant information regarding my medical history and current health status;

I am making use of the facilities and services of Move Exercise Physiology of my own free will;

I understand that any gym or clinic that Move Exercise Physiology conducts services in is not liable for any injury, theft, loss, or damage;

I assume all risks associated therewith

*

Accounts
I understand that payment for my account is my responsibility and all accounts must be paid on day of service. If any account is not paid within (30) days, I agree to pay all expenses incurred by you in pursuing recovery of overdue amounts, including (but not limited to) legal fees, administrative costs and commission to debt recover consultants. Insurance Compensation patients, please note that the responsibility of accounts is yours until such time that your claim is accepted by the insurance body. Accounts will be held in abeyance until such time as a decision is made. *

SIGNATURE

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DATE SIGNED