Wellspring Pain Clinic Sydney | Chronic Pain Management & Treatment

Personal Information

First Name *

Surname *

Title *

MissMrsMrMsDr

Other title

Date of birth *

Address *

Postcode *

Phone - Mobile *

Phone - Home

Phone - Work

Email Address *

Medicare

Medicare Number *

Reference *

Expiry date *

Private Insurance

Do you have private insurance? *

YesNo

Name of Health fund:

Membership number:

Pension Fund

Do you have a Pension Card?

YesNo

Pension Number

Veterans Affairs

Veterans Affairs Number:

Colour of Card:

Workcover Claim

Is this a Workcover Claim? *

YesNo

Is Workcover approval for appointment?

YesNo

Claim No.

Claim contact details:

Your usual General Practitioner

GP's Name *

Dr

GP Practice Name *

Practice Address:

Postcode:

Practice Phone Number:

Person responsible for the account IF other than the patient

Name:

Phone Number

Address:

EMERGENCY CONTACT

Emergency Contact Name *

Address:

Postcode:

Relationship to you:

Phone - Mobile *

Phone - Home

Phone - Work

Consent

Consent to Treatment: *

Yes, I consent to treatment.

Consent to Share Information: *

Yes, I consent to share my information with healthcare providers.

Consent to Clinical Photography: (optional)

I consent to clinical photographs being taken during consultations and used for my treatment and medical records. This is optional and my care will not be affected if I decline.

YesNo

Consent to Release Information: *

Yes, I consent to the release of my medical information.

Consent to Medical Students: (optional)

I consent to medical students being present to observe my consultation. This is optional and my care will not be affected if I decline.

YesNo

Consent to Fee Schedule: (optional)

I have read and agree to the clinic's schedule of fees for consultations and procedures. This is optional and does not affect your ability to receive care.

YesNo

Consent to Overseas Handling of My Information: *

Yes, I consent to my personal and health information being handled by the clinic's service providers, including its third-party IT provider, Amazon Web Services (AWS) and Google (Gmail). Some of this information may be stored or processed overseas, including in the United States, where privacy laws may differ from Australia's.

Privacy Policy & Collection Consent: *

Yes, I have read the Privacy Policy and consent to the collection, use and disclosure of my personal and health information as described in it.

I have been provided with a schedule of relevant fees for the practice and have viewed them to my satisfaction and have had the opportunity to ask any questions prior to consultation.

I understand that I am responsible for payment of all services rendered on my behalf and agree to pay for services. I hereby certify that the information provided is true and accurate to the best of my knowledge.

I acknowledge that I have read and understand all of the above *

Online Patient Registration Form

Patient Registration and Consent

Personal Information

Medicare

Private Insurance

Pension Fund

Veterans Affairs

Workcover Claim

Your usual General Practitioner

Person responsible for the account IF other than the patient

EMERGENCY CONTACT

Consent