Patient Registration Form

New Patient Registration FormFilling out your patient registration form online in the comfort of your own home will save you time at your appointment and helps us ensure that your details are recorded accurately. If you are unable to do this, we ask that you please attend the clinic 10 minutes prior to your appointment time.

Which podiatry centre do you intend to visit?

1) Tell us about yourself:

Unit / Street No:
Street Name:
Suburb / City:
State / Post Code:

2) Who should we contact in case of an emergency?

3) Were you referred by a Doctor or Allied Health Practitioner?

4) Do you have private health insurance for podiatry?

5) Do you have a Team Care Arrangement / EPC referral?

6) Are you covered by Department of Veterans' Affairs (DVA)?

7) Are you covered by National Disability Insurance Scheme?

8) Are you seeing us under a Work Cover claim?

9) How did you find out about us?