Client Details

Client Full Name *

Date of Birth *

Gender
—Please choose an option—MaleFemaleNot statedOther

Phone Number *

Email Address *

Address

Best Mobile Number for Appointment Reminders

Medicare Details

Please provide your Medicare details if you would like us to process your Medicare claim through Tyro. If you prefer, you can bring your Medicare card to your appointment instead.

Medicare Card Number

Individual Reference Number, IRN

Medicare Card Expiry

Name as Shown on Medicare Card

Do you have a current GP referral / EPC / Chronic Disease Management referral?
—Please choose an option—YesNoUnsureI will bring it to my appointment

Health Information

Description of Condition

Relevant Medical History

Mobility Requirements

Walking independentlyWalking with aidsWeight bearingTransfers independentlyTransfers with assistanceSlide boardHoistManual wheelchairPower wheelchairWalkerWalking stickNo mobility assistance requiredOther

If other, please provide details

Goals / Changes to be Achieved

Emergency Contact

Emergency Contact Name *

Relationship to Client *

Phone Number *

Email

Authorised Representative

Please complete this section if someone else is authorised to sign documentation or communicate with us on behalf of the client.

Who will be signing documentation?
—Please choose an option—ClientEmergency contactParent / GuardianOther

Authorised Representative Name

Phone

Email

GP Contact Details

GP Name

Medical Practice

Phone

Email

Referral Information

How did you hear about us?

Internet / GoogleAllied Health ProfessionalGPWord of mouthOther

Please provide details if relevant

Document Uploads

You can upload your GP referral, relevant medical history, medication list, or other supporting documents below.

GP Referral / EPC / Medicare Referral

Medical History / Medication List / Other Supporting Documents

Form Completed By

Your Name *

Date Completed

I confirm that the information provided is accurate to the best of my knowledge and consent to Combined Wellness Solutions using this information to set up the client in the system, prepare for appointments, communicate with relevant parties where required, and process Medicare claiming where applicable.