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 *

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 Photos: *

Yes, I consent to having my photos taken during consultations.

Consent to Release Information: *

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

Consent to Medical Students: *

Yes, I consent to medical students observing my consultation.

Consent to Fee Schedule: *

Yes, I consent to the fee schedule for consultations.

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