Home
Dr. Belinda Thewes
Telehealth
FOR CLIENTS
FAQs
Fees
Bookings
Resources
Online Consent Form
Online Registration
NDIS Service Agreement
Online Payment
Videos
FOR HEALTH PROFESSIONALS
Referrals
Publications
Qualifications
Videos
Policies
Policies and Procedures Guide For Private Practices
We Care
Contact
.
Home
Dr. Belinda Thewes
Telehealth
FOR CLIENTS
FAQs
Fees
Bookings
Resources
Online Consent Form
Online Registration
NDIS Service Agreement
Online Payment
Videos
FOR HEALTH PROFESSIONALS
Referrals
Publications
Qualifications
Videos
Policies
Policies and Procedures Guide For Private Practices
We Care
Contact
.
Date
MM
DD
YYYY
CLIENT DETAILS
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone (Landline)
Phone (Mobile)
MEDICARE DETAILS
Name on card
Medicare Number
Individual number on card
Expiry
MM
DD
YYYY
NDIS (If applicable)
Support Coordinator / Plan Manager
Plan Number
PRIVATE HEALTH FUND (If applicable)
Name on card
Health fund
Card number
DVA Details (If applicable)
Type of card
Select your card type
Gold card
White card
Name on card
Number
YOUR TREATMENT TEAM
Please provide below the names of any health professionals with whom you would like us to communicate with about your care.
GENERAL PRACTITIONER
Name
Practice Name
MEDICAL SPECIALIST
Name
Specialist type
Practice / Location
OTHER HEALTH PROFESSIONALS
Name
Specialist type
Practice Name / Location
EMERGENCY CONTACTS
In the event of a medical emergency who would you like us to contact?
EMERGENCY CONTACT 1
Name
*
Relationship to you
*
Phone (Landline)
*
Phone (Mobile)
*
EMERGENCY CONTACT 2
Name
*
Relationship to you
*
Phone (Landline)
*
Phone (Mobile)
*
PREFERRED CONTACT METHOD(S)
Landline
Mobile
Email (for administrative matters only)
SMS (for appointment reminders)
All the above are ok
PAYMENT SOURCE
Therapist fee with Medicare Rebate (Mental Health Care Plan)
Therapist fee with Private Health Cover Rebate
DVA
NDIS
Insurance company
Other
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