Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Type of service required *Please selectPodiatryPhysiotherapyPodiatry & PhysiotherapySpeech PathologyPlease select service(s) required: *PhysiotherapyPodiatrySpeech PathologyOccupational TherapyName of client *FirstLastClient Date of Birth *Residential address *Suburb and Postcode *Home phone number *Mobile phone numberEmail addressDoes the client have Private Health Insurance?YesNoUnsureAre Extras including Podiatry and Physiotherapy covered under their Private Health Insurance?YesNoUnsureWhich Health Insurance does the client hold?MedibankBupaHCFGMHBAAHMOtherDoes the client hold a Medicare Referral (EPC/CDM)?YesNoUnsureReason for referralRelevant medical historyAllergiesCurrent Medication (prescriptions, over-the-counter and Vitamins):Please provide Emergency Contact/Next of Kin: Full name Relation to Emergency Contact/Next of Kin Emergency Contact/Next of Kin: Phone NumberAdditional comments (if required)Click here to download Risk Assessment FormPlease attach all relevant client documents, including: completed risk assessment and referral forms Click or drag files to this area to upload. You can upload up to 20 files. Please note that BMHG must receive a completed risk assessment and valid Medicare referral in order for services to be completed and the medicare rebate to be applicable.I agree to BMHG’s cancellation policI have read and understood the Bluey Mobile Health Group cancellation policyBMHG’s Cancellation PolicyConsent to treatment *I agree to receiving treatmentI have read the above information and understand the reasons Bluey Mobile Health Group collect my personal information and how it is used. I know that it is my choice what information I provide. However, I also understand that withholding information may be detrimental to my treatment. I understand there may be a need to collect further information from other sources, such as radiography reports and/or medical reports. I am aware that I can access and/or correct my personal and treatment information on request. I understand I am financially responsible for any balance due on my account. I consent to podiatry treatment being undertaken by the podiatrist. I understand that Bluey Mobile Health Group will explain all treatments before being administered. I understand I can verbally withdraw consent at any time.Privacy policy *I have read and understood the Bluey Mobile Health Group Privacy PolicyThere is now a legal requirement that we gain your consent to collect and use personal information about you. Please read the following carefully and sign the declaration if you consent to Bluey Mobile Health Group to collect this information. In order to assess, diagnose, and treat you, Bluey Mobile Health Group needs to collect some personal and medical information from you. We may also use this information for: The administrative purposes of running the practice. Billing, either directly or through a third party. Use within the organisation when giving information to other clinical staff for your ongoing treatment and care. Disclosure of treatment and medical information to your or other clinical treatment providers.Please detail how you heard about usPrint this pageSubmit