New Client Registration Form (Community)
Client Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date
Gender
Please Select
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Mobile
Please enter a valid phone number.
Identity
Please Select
Aboriginal
Torres Strait Islander
Both
Neither
If you are neither, unfortunately you are not eligible for ITC services. Please do not continue with the form.
Health Care Card
Health Care Card Expiry
/
Day
/
Month
Year
Date
Medicare Card
Medicare Card Expiry
/
Day
/
Month
Year
Date
Chronic Condition
Diabetes
Cancer
Cardiovascular
Renal
Respiratory
Eye health condition associated with diabetes
Client's GP
Practice Name
GP Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
GP Phone Number
Please enter a valid phone number.
GP Fax Number
Please enter a valid phone number.
Complex care needs?
Please Select
Yes
No
Please Specify
Chronic Disease GP Management Care Plan?
Please Select
Yes (Please attach)
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a Carer?
Please Select
Yes
No
Carer's Name
Carer's Contact Number
Please enter a valid phone number.
Referrer Name
First Name
Last Name
Organisation
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Referrer Signature
I have discussed the proposed referral to the ITC Program with the patient and am satisfied that the patient understands and is able to provide informed consent to this referral.
Client Consent
The referrer has spoken to me about ITC Program and provided me with a fact sheet.
I understand that my participation is voluntary, and that I have the right to withdraw from the program at any time.
I understand that a range of health and community service providers may collect, use and disclose myrelevant personal information as part of my care.
I understand that the personal information collected by these organisations will be maintained in a manner consistent with National Privacy Principles. It will remain confidential except when it is a legal requirement to disclose information; or where failure to disclose information would place me or another person at risk; or when my written consent has been obtained to release the information to a third party.
I understand that statistical information (that will not identify me) will be collected and used to see how well the Program is working and help improve services for Aboriginal and Torres Strait Islander people.
Verbal Consent
Client has given verbal consent
The following people have permission to discuss my health care needs and plans within the ITC program:
My Carer listed above
Other people (List below)
List other people
Client's Signature
Continue
Continue
Should be Empty: