Monday to Friday: 8.30am - 5.00pm
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Optimise Health and Wellness

Patient Registration Form

    Contact Information

    Would you like appointment reminders via SMS?

     

    Ethnicity

    Are you Aboriginal or Torres Strait Islander?*

     

    Next of Kin

     

    Card Information - Medicare, Pension, Health and PVA

     

    Preferred GP

     

    Consent to sharing of information

    I, consent to Optimise Health and Wellness, sharing and gaining information (written or verbal) relevant to my health care needs with people involved in my care as listed below:


    All information gathered by this clinic is confidential and is only available to authorised staff members. Accessing such information is used to provide comprehensive holistic care.

     

    Photo Release Consent

    Do you grant permission to Optimise Health and Wellness to use photographs and/or videos of you in:


    Publications*

    News Releases*

    Online (website, social media etc.)*

     

    Non-Attendance Policy

    Please understand that we have several participants on our wait list who would like to book an appointment. We require you to contact us at least one day prior to your appointment (other than NDIS participants) if you are not able to attend your scheduled visit. With such notice, we can reschedule your appointment and allocate your previously assigned time to another participant.


    If notice is not received one day prior, a nonattendance fee of $35.00 will be charged. Please note, Medicare will not allow us to charge them nonattendance fees and this is the responsibility of the participant.


    You will receive appointment confirmation the day prior to your appointment time, should you need to reschedule your appointment, please contact Optimise Health and Wellness by calling our friendly receptionist on 4423 7662 or by texting our reception mobile 0421 660 712.


    By submitting this form, you understand and agree to, the nonattendance policy outlined above.


    Please discuss any concerns or queries you may have with your clinician. Should extenuating circumstances arise Optimise Health and Wellness Management reserve the right to waive the above fees at their discretion.

     
     

    Overall Consent

    I have read and understood this form and I consent to the use of my information as described:


    Optimise Health and Wellness