Patient Case Review

Health Insurance Booking Form
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Date
Insurance Provider

WPA BUPA AXA Simplyhealth Beneden CIGNA Medicash Vitality
Insurance Policy Number
Insurance Authorisation Code
Preferred Clinic Location
Do you have an Excess on your policy?
How much is your excess?
Preferred Appointment Date and Time (This appointment is not confirmed until we contact you)
Once you have submitted your form a member of The Physio Lounge Team will contact you to confirm or arrange your appointment.

Due to Covid 19 restrictions if you have selected a Clinic other than "Online" we will book you a 10-minute Covid Screening phone call with one of our Physiotherapists.

The Physio will then advise if you will be seen face to face or managed virtually via video consultation.
Should be Empty:

Health Insurance Booking Form