PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

Gender

MaleFemale

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Email

Address

Postcode

City / Suburb

State

EMERGENCY CONTACT DETAILS

Next of Kin - Name

Mobile Phone

Email

HEALTH SCREENING

REFERRING DOCTOR TO US

Referring Doctor’s Name

Address

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

Address

MEDICARE

Do you use a different name in your medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No.

Individual Reference No.

Expiry

PRIVATE HEALTH INSURANCE

Do you have private health insurance

YesNo

Provider

Membership No.

Individual Reference 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 No.

CONSENT

I consent to receive medical evaluation and treatment at Undisputed Performance & Rehab. I understand the purpose, risks, and benefits, and I authorize the disclosure and use of my medical information. I acknowledge my right to refuse or modify treatment and take financial responsibility for services. I agree to emergency contacts and communication methods. I also understand the potential use of telemedicine. My personal and medical information will be kept confidential, and I consent to the healthcare practice's policies.

SIGNATURE

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

I agree to the consent statement, as above *

I consent to email and SMS marketing.

Patient/ Guardian Signature

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