• Mid Coast Integrative Health New Patient Registration Form

    Mid Coast Integrative Health New Patient Registration Form

    Please complete this form to register as a new patient. Your information will help us provide you with the best possible care. *If unbale to provide an answer, type "NA" into the field.
  • Date of Birth*
     / /
  • Medicare Expiry Date*
     / /
  • DVA Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Consent to Text Reminders*
  • Consent to Email Communictaion*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Emergency Contact Same as Next of Kin*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Aboriginal or Torres Strait Islander*
  • Consent to Contact Next of Kin if Unreachable*
  • Agree to Personal Electronic Health Record*
  • Already Have Electronic Health Record*
  • Medicare Online Account Set Up*
  • Smoking Status*

  • Patient Agreement

    Dear Patient,
    Thankyou for considering becoming a patient at Mid Coast Integrative Health.
    The majority of conditions have a clear cause and assisting people determine and correct the cause while managing symptoms to improve quality of life and optimise wellness in a partnership with the patient is the focus of our care.
    To achieve this we use GP Management Plans, Team Care Arrangements, Health Assessments, Cycles of Care for chronic conditions, Pharmacist assisted medication reviews, My Medicare Registrations, referrals to specialists and allied health professionals, nutrition assessments and plans, GP Mental
    Health Care Plans, mental health consults, focussed psychological strategy sessions, and other services.
    This is a private billing clinic however I am committed to assisting you in maximising your medicare rebate.
    The method of contact I use is email. I am happy to be contacted via email and I will reach out via email with check ins, recalls, and reminders as needed.
    If you agree to the above approach to your medical care please sign below and we will assist you to transfer your records to our practice.

  • Agreement to Partnership Care*
  • Patient Agreement Date*
     - -

  • Record and Investigations Transfer Request

    Dear GP/ Surgery/ Pathology/ Imaging provider,
    The following patient is transferring care to our practice.
    This form is requesting transfer of patient records as soon as possible.
    Mid Coast Integrative Health utilises Best Practice for record keeping and we would appreciate the
    record to be stored on a USB or disc so we can transfer records easily.
    Please see patient details and consent below.

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Consent for Transfer*
  • Signature Date*
     - -
  • Should be Empty: