NDIS Service Request Form -
Thank you for making your first appointment with Our Healthcare Australia. This form is intended for NDIS Support Coordinators and NDIS participants. Please be advised Our Healthcare Australia is currently only able to see Self or Plan managed Participants. If you’re unsure if the participant is NDIA/Agency managed, please call 0419 230 307 to discuss prior to completing form.
Name of participant
First Name
Last Name
Type of service required
Please Select
Podiatry
Participant date of birth
Participant residential address
Participant home phone number
Participant mobile phone number
NDIS #
Reason for service
Medical History / Medications
Safety concerns Our Healthcare Australia should be aware of: (if any)
How is the participant managed
Please Select
Self Managed
Plan Managed
NDIA managed
NDIS plan start date
NDIS plan end date
Support co-ordinator name
First Name
Last Name
Support co-ordinator email
Support co-ordinator phone number
Email for invoices
If participant is unable to sign, please provide alternate contact email responsible for signing service agreement on behalf of the participant
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Please provide a copy of NDIS Plan or NDIS Plan goals and any relevant reports or referrals
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Is an allied health report required post initial assessment?
Yes
No
Please confirm participant is not NDIA managed: (Our Healthcare Australia is currently only able to see self and plan managed participants. If you are unsure , please call 0419 230 307
The participant is NOT NDIA/Agency managed
I have reviewed the information provided above and comprehend the reasons for Our Healthcare Australia collecting my personal information and how it will be utilized. I acknowledge that the decision to provide information is up to me, but understand that failing to do so may negatively impact my treatment. I am aware that additional information may be gathered from sources such as medical and imaging reports. I have the right to access and modify my personal information and treatment records upon request. I accept financial responsibility for any outstanding balances on my account. I give my consent for the podiatrist to perform the podiatry treatment. I acknowledge that Our Health Care Australia will thoroughly explain all procedures before they are carried out. I have the option to revoke my consent at any time verbally.
I agree to receiving treatment performed by Our Healthcare Australia
Privacy Policy: As per legal requirements, we require your consent to collect and utilize your personal information. Please take the time to carefully read the following and sign the declaration if you agree to allow Our Healthcare Australia to gather this information. To effectively evaluate, diagnose, and treat you, Our Healthcare Australia must collect some personal and medical information from you. This information may also be utilized for the following purposes: Managing and operating the practice. Billing procedures, either directly or through a third party. Sharing information with other clinical staff within the organization for ongoing treatment and care. Disclosing your treatment and medical information to you or other healthcare providers.
I have read and understood Our Healthcare Australia's privacy policy
I am not a robot
*
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