Patient Details Form

COVID-19

Due to the current health advice surrounding the Coronavirus (Covid-19), you must agree you have NOT travelled overseas within the past 14 days, OR come in contact with someone that has tested positive for Covid-19. You must also agree you are NOT showing any cold or flu-like symptoms, including sore throat and fever and that you will bring only ONE support person with you to your appointment.

To Which Doctor Have You Been Referred

Details

GP

Next of Kin

Contacting You

Briz Brain & Spine ensures all measures are taken to protect the patient's privacy. In the event that Briz Brain and Spine need to contact you, we will attempt to contact you on the above listed contact numbers. Should you have an answering service attached to the above contact number/s or if another member of your household answers, please sign below to consent to Briz Brain & Spine leaving a message for you.

If you do not wish a message to be left please indicate below.

Briz Brain & Spine to contact me on the above contact number/s and request that a return message be left in the event that I am unable to speak with Briz Brain & Spine directly.

Private Health Insurance

This practice does not bill to third parties such as WorkCover without previous written approval being received from your Case Manager.

IF YOU ARE NOT THE PERSON RESPONSIBLE FOR THE ACCOUNT YOU WILL NEED TO SUBMIT DOCUMENTATION OUTLINING THE PERSON RESPONSIBLE FOR THE ACCOUNT (THIS APPLIES TO PRIVATE PATIENTS ONLY)