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

No

Contact

Phone

Email

Address

Country

City

State

Postcode

Communication

Consent

Reminders

Marketing

Extra Information

Emergency Contact Details

How did you hear about us?

Medicare Details

Payer/Insurance Details

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

Please sign below and click "Accept" upon consent*