Telehealth Registration

Name *

First

Last

Preferred Name

Birthday *

DD/MM/YYYY

Email *

Mobile Phone Number *

Address *

Medicare Number *

Please include card number, your reference number on the card, and expiry date.

Private Health Fund *

First

Last

GP *

First

Last

Referring Doctor (if applicable)

Next of Kin *

First

Last

Service Required *

Briefly describe the nature of your condition *

Have you had treatment for this condition before? *

Yes
No

Medical History- Do you have any of the following? *

Cardiac Pacemaker/ any other devices
Metal Implants
Currently Pregnant
None of the above

Please select any that apply to you.

Do you/ have you had any of the following health problems? *

Please select any that apply to you.

I accept that telehealth consultations are to be paid in full prior to consultation going ahead. *

Accept

I acknowledge that I have been given the opportunity to read the Sportreat Information on the Privacy Act 1988. *

Accept

please click hyperlink below this form to view our privacy policy.

I provide my consent for Sportreat Health Care Providers to collect, use and disclose my personal information as outlined in the Sportreat Information on the Privacy Act 1988. *

Accept

I understand that I may withdraw my consent as to use and disclosure of my personal information (except when legal obligations must be met). *

Accept

I understand that I am entitled to access my own health records except where access would be denied as outlined in the Sportreat Information on the Privacy Act 1988. *

Accept

Authorisation to collect and provide records/ results. *

Accept

We may need to collect relevant information regarding you from various pathology laboratories, radiology facilities, or from other doctors, specialists, or other health care providers. This authorisation will allow us to collect and disclose information to your referring doctor in the interest of providing you the best possible patient care.

Telehealth Consultations at Sportreat