Patient Details Form
REFERRING DOCTOR INFORMATION
Name
First Name
Last Name
Email
example@example.com
Phone Number
PATIENT CONTACT INFORMATION
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Contact Number
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Private Health
Private Health Details
Name of medical fund
Policy Number
Reference #
Medicare
Card Number
Reference #
Valid until
-
Month
-
Day
Year
Date
Next of Kin
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
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General Practitioner
Helpful to provide feedback on your care
Name
First Name
Last Name
Email
example@example.com
Reason for Referral
Lipoedema management
Lymphoedema management
Hand Therapy
Other
Please upload any referrals or supporting documentation
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Terms and Conditions
Your Personal Health Information and your Health Record may be collected, used and disclosed for the following reasons: For communicating with other treating medical professionals, for follow-up/reminder calls, for use by all therapists in this practice when consulting with you and for legal disclosure as required by a court of law. If you have any concerns regarding your information please discuss this with your therapist. This practice adheres to National Privacy Principles (www.privacy.gov.au) and has a written policy available for your perusal at www.lymphbalance.com.au. All Therapists at this practice hold full Indemnity Insurance as stipulated by AHPRA and registrations ALA and NLPR.
Yes
No
Your informed consent is required for all treatment provided by this practice. You may withdraw your consent at any time. Treatment will cease if consent is withdrawn. If you become uncomfortable with your treatment at any time please inform your therapist. All forms of treatment carry some risk. Risks will be explained prior to treatment at which time you may choose to continue or discontinue treatment. I give consent for treatment. I agree to this consent remaining valid until such time as I withdraw my consent. I also agree and give consent for my case to be discussed with interested parties.
Yes
No
I consent to treatment with low level laser therapy as appropriate as fully explained to me by my therapist.
Yes
No
Payment terms and conditions: I understand that I will be personally responsible for my accounts if a third party payment is not accepted. I understand that a minimum of 24 hours notice is required to cancel or reschedule my appointment, and that a fee of $90 may be applicable at the discretion of Lymph Balance should this requirement not be met. I also understand that all garments ordered on my behalf are to be paid for in full at the time of ordering and all garments require an appointment for fitting. All accounts are to be paid in full at time of consultation. Initial consultation: $185, Standard follow up: $165, Short follow up: $135.
Yes
No
I consent to my photographs being used in the following capacity:Photographs help us improve care through education, raise awareness about our services, and track patient progress. Please indicate your consent for the following:
Record Keeping: I understand that my photographs will be stored securely and used according to my selected consents.
Marketing Use: I consent to the use of my photographs for marketing purposes (e.g., brochures, website, social media).
Educational Use: I consent to the use of my photographs for educational purposes (e.g., presentations, training materials).
I do not consent
Signature
I hereby confirm that I have carefully reviewed all the information provided in this patient intake form, including but not limited to my personal details, medical history, consent for treatment, financial agreements, and office policies. I understand the contents of this form and agree to provide accurate and complete information to the best of my knowledge. I acknowledge that it is my responsibility to inform the healthcare provider of any changes to my information or medical status. By signing below, I authorise Lymph Balance to collect, use, and disclose my personal and medical information for the purpose of providing healthcare services and for administrative, billing, and operational purposes as described in the privacy policy.
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