Active One Client Registration Form

Title

First name

Middle Name

Last name

Preferred Name

Date of Birth

Gender

Male

Female

Other

Are you of Aboriginal or Torres Strait Islander origin?

Yes

Contact

Phone

Residential Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Is your postal address different from your residential address?

Communication

Consent

Reminders

Marketing

Extra Information

Emergency Contact Details

Phone

Relationship to client:

GP Details

GP Name

Phone

GP Clinic Name/Address

How did you hear about us?

i.e. Google, Facebook, Friend or Family (name?), GP/Specialist (name?), other (please specify)

Medicare Details

Medicare Card Reference Number

Expiry Date

(month/year)

Treatment

Reason for Visit

Informed Consent

In order to provide and maintain comprehensive care to me and to abide by legal requirements, I CONSENT TO:

Ø the collection, use and disclosure of my personal health information in accordance with the Privacy Legislation.

Ø the sharing (collecting and disclosing) of my health information with all relevant person/s involved in my healthcare. These may include, for example, my doctor or health professionals, my family, other next of kin, an informal advocate or an authorised representative.

Ø the use of my information for data collection, research and education purposes, on the condition that all information will be de-identified prior to use.

I confirm that I have read and accept Active One Group's Cancellation Policy (less than 24 hrs notice).

Signature

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