Client Registration Form

    Are you happy to receive SMS appointment reminders? YESNO

    Are you happy to receive latest updates from Restore via email?YESNO

    Do you have private health insurance EXTRAS COVER?YESNO

    How did you hear about our Practice?

    Do you have a written referral? YESNO

    Is this consultation

    • Payment of consultation is required on the day

    • We accept cash, cheque, EFTPOS and credit card (Mastercard/Visa)

    • Direct Health Fund claiming on the spot is available through HICAPS

    We require at least 24 hours notice of changes to appointment times
    Failure to do so will incur a cancellation fee

    Your health information and our privacy policy

    In accordance with the Victorian Health Records Act 2001 and Privacy Act

    Our practice respects your rights to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed.

    The policy of our practice is to follow these procedures:

    1. The information collected will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you, as well as processing payments and writing to you about our service and any issues affecting your treatment.

    2. We may disclose or receive information regarding your health from other health care professionals. In this event, disclosure of your personal details will be minimised wherever possible.

    3. We may use parts of your health information for research purposes, in study groups or at seminars as this may provide benefit to other patients. Should that happen, your personal identity will not be disclosed.

    4. Your record, and other material relevant to your treatment will be retained (in some cases for a limited period). You may inspect or request copies of our records, or seek an explanation of your treatment.

    5. If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly.

    6. Your health information will be treated with utmost confidentiality. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.