Halaxy - Patient Details

Patient Details

* Patient

Patient Details Contacts Addresses

Payment Details

Funding

Department of Veteran Affairs (DVA) Medicare Private Private Health Insurance

Bank Account Indigenous status (optional) * Patient Service Agreement * Patient Informed Consent to Physiotherapy * Mark Completed

Patient

Privacy and Information Collection Notice

To provide you with the best possible care, our practice collects personal, billing, and clinical health information.

How we use your details:

Clinical Management: To understand your health history and provide safe, high-quality treatment.
Administration: To manage your appointments, process billing, and handle funding or Medicare claims.
Care Coordination: To securely communicate with relevant members of your healthcare team (such as your GP).

Your information is handled with the highest level of security and kept strictly confidential in accordance with national privacy laws. I have attached our full Privacy Policy for you to review during this process.

Patient Details

* Name

Title

* First Name

Middle Name

Surname

Preferred Name

Date of Birth

Gender

Contact Email

* Timezone

Phone Numbers

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Introduction Source

Please let us know how you found our clinic or who referred you, so we can meet our clinical reporting requirements and properly coordinate your care.

* Introduction Source

* Mandatory questions