EP Services Referral

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Name: *

Contact Number: *

Email: *

Suburb/Postcode:

Emergency contact Name: *

Emergency contact Number: *

D.O.B

Do you have an open workers compensation claim?

Yes

Injury/condition/reason for referral:

Preferred Consultant:

Are you eligible for Medicare rebate through a GP Management Plan(GPMP) or Team Care Arrangement(TCA)

(Please attach or send through to [email protected])

Payment Options *

Self funded

Medicare

Private Health

*Payment requirements

Please note that all Medicare, self-funded or private health insurance AEP sessions will need to be paid for by the client in full at the time of consultation. Any rebates from Medicare or private health funds will need to be sought by the client independently.

GP Name and Practice:

Specialist Name and Practice:

Phone

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YOUR GOALS, YOUR WAY

WE CARE, WE CAN

18000-73422 (REHAB)