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Occupational Therapist e-Form

Please fill out the following Patient Registration e-Form with your details and click the submit button to confirm your appointment as required.
Effectively from 01/02/23 OT fees are payable on the day of the consultation by cash or EFTPOS for appts in the clinic. For outside the clinic appts (home or school visits) fees are payable on the day of the consultation or any other day by authorising the clinic to debit your credit or debit card shared as per our updated policies and procedures (please see below).

(Please fill out all the fields) (Form: occuthinitial)

Child's (Patient) Details

Date of Birth

Address

Parent 1 Details (Primary account holder and person to contact)

Date of Birth

Please check/click this box if "Parent 1" does not wish to share any information with anyone.

Parent 2 Details (Secondary person we can share information )

Date of Birth

Additional Required Information

Reason for referral and any areas of key concern:

Feel free to discuss any areas of development or early years that may be relevant eg pregnancy/ birth/IVF/child hood developmental milestones:

We are interested in sensory processing, this plays a big part in both adults and children's lives. Please feel free to make note any comments that may be relevant:

We are interested in motor planning aspects,details related to strengths and challenges in relation to gross and fine motor skills and also daily life, eg getting ready in the morning:

Feel free to note anything else that you would like to share to help us get to know and understand your child:

Medicare Card Details

PRIVACY INFORMATION AND CONSENT

** Please click here to read the Privacy & Parent Consent Information before continuing with this form (pdf file)

Yes, I agree to the privacy and parent consent information above.

Payment Details

Credit Card Type
Card Number:
Please upload referral or related documents