Client Registration Name * First Name Last Name Date of Birth * MM DD YYYY Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Medicare Number * The main number on your Medicare card Medicare Person Number * The number next to your name on your Medicare card Medicare Expiry Month * Medicare Expiry Year * Credit Card Number * This is required for Telehealth sessions and in the event of not attending a session Credit Card Expiry Date * Credit Card CVV * The number on the back of your credit card General Practitioner's Name * Emergency Contact * Emergency Contact Relationship to You? * Emergency Contact Phone * (###) ### #### 1. I have read and understood the Consent Form. I agree to these conditions for the psychological services provided. * Yes 2. I understand that I am responsible for the full amount of my bill for the services provided. * Yes 3. I understand that I am responsible for payment for each appointment on the day it is provided. * Yes 4. I understand that there is a one business day cancellation policy, which requires that I cancel my appointment at least one business day in advance, or I will be charged the normal fee plus GST. * Yes 5. I understand that I will be responsible for the costs incurred on the collection of outstanding debts. * Yes 6. I understand that if I miss an appointment and do not give any notice then all subsequent appointments I may have made will be cancelled. * Yes 7. I give permission for my treating psychologist to liaise with my referring medical practitioner in whatever manner is deemed appropriate, and to provide reports as required or indicated. * Yes 8. I give my permission for my treating psychologist to obtain information from Medicare or DVA, as appropriate, in order to provide rebates. * Yes Thank you!
