Patient Registration Form

  • Privacy Consent

    Permission is given to collect and release information on my medical history in order to provide appropriate healthcare. In addition I understand certain information may be used for medical research and audit purposes. A Copy of our privacy policy is available upon request.
    Account: I understand that it is my responsibility to pay my account at the time of my consultation. I undertake to pay any addition expenses incurred in recovering overdue fees.
  • Date Format: MM slash DD slash YYYY
  • Parent / Guardian Consent

    If patient is less than 18 years of age.
  • Date Format: MM slash DD slash YYYY
  • Worker's Compensation / Third party

    Workers Compensation / Third Party I declare that this is an accepted insurance company claim. I understand if the claim is declined I must pay the consultation cost expected at the time of consult. If at any stage the claim is denied I must pay any outstanding accounts.
  • Date Format: MM slash DD slash YYYY