Form5 Customer Registration

Customer Registration
First Name
as per the Medicare Card
Last Name
as per the Medicare Card
Street Address (without Suburb,State or Postal Code)
*please type only the street address without the suburb
Suburb
State
Postal Code
Date of Birth

DayMonthYear
Gender
Medicare Card/NDIS Number
Please enter Medicare Card/NDIS Number Ex: 3501 80315 1
Medicare Card Reference Number
What's the number to the left of your name on the Medicare card? *
Medicare Card Expiry Details
Mobile Primary
Please enter your mobile number starting with 04Format: 0000000000.
Secondary Number
Please enter a secondary phone numberFormat: 0000000000.
Email
Next of Kin Name
Next of Kin Phone
Case Worker/Representative
Please select a date and time within the next 10 days for a quick 5-minute onboarding call with our support coordinator via Zoom/Google Meet.
How did you find us?

Other [Please state]
Can we get your consent to check your consultation history with Medicare? We may require this in order to check your entitlement for services provided
For Psychiatry Clients
Have you seen another psychiatrist in the past 12 months?
If you are wanting an ADHD assessment; does your referral clearly state that you are needing an ADHD assessment?
For Psychology Clients
Have you seen another psychologist or counsellor, this year, using a mental health care plan?
For office use only
File Name Generator Unique ID
GP & GP Clinic Details
GP Name
*
GP Provider Number
*
GP Clinic Name
*
GP Clinic Address
*
GP Clinic Fax Number
*
GP Clinic Email
Epsychiatry Clinician Details
Clinician Name
If the client has changed the GP

Please add new GP's name, GP clinic name and the address to the New GP Details below
New GP Details
Notes
Client Status
Should be Empty:

Customer Registration

Medicare Card Reference Number

For Psychiatry Clients

For Psychology Clients

GP & GP Clinic Details

Epsychiatry Clinician Details

If the client has changed the GP