Registration

Patient Registration Form

PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

Gender

MaleFemale

ATSI

AboriginalTorres Strait IslanderNone of the Above

PATIENT CONTACT DETAILS

Mobile Phone *

Email

Address

Postcode

City / Suburb

State

EMERGENCY CONTACT DETAILS

Name

Address

Postcode

City / Suburb

State

Mobile Phone

Email

Work Phone

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin Home Phone

Next of kin - Mobile Phone

REFERRING DOCTOR TO US

Referring Doctor’s Name

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.

Expiry

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Provider

Membership 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.

SIGNATURE

I acknowledge that I have read the terms and conditions of taking part in counselling/psychotherapy at JUST NOTICE Counselling and Consultancy.

I acknowledge I have read the cancellation policy and confidentiality agreement at JUST NOTICE Counselling and Consultancy.

I acknowledte the fee agreement.

Please click on the link below to read the Terms and Conditions, Fee Scheule and other important information.

https://www.justnotice.com.au/faq#faq

I give consent for Renee Cassidy @ JUST NOTICE Counselling and Consultancy to process the Medicare rebate into my nominated account attached to Medicare. Should bulk billing be agreed upon, I consent for Renee Cassidy to be paid the bulk billing amount via Medicare once this has been process via Proda @ MyGOV services

The link is below for telehealth video sessions:

https://us06web.zoom.us/j/3653140468?pwd=iOdQgiISVx117ZaNtHg0t7eQCucw7c.1

Meeting ID: 365 314 0468
Passcode: justnotice

*

Patient/ Guardian Signature

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