General Patient Information:
Parent or Guardian Details (patients under 18)
Emergency Contact Information:
Your Insurance Information:
Confidential Patient History:
Please answer all questions as accurately and completely as possible. The details you provide help your practitioner give you safe, effective care. Leaving things out — even details that seem unrelated — may affect your diagnosis and treatment.
By submitting this form, I (or the parent/guardian if the patient is under 18) agree to pay for all treatments and services on the day they are provided. I understand that a non-attendance fee — equal to the full cost of the missed consultation — applies if I cancel or reschedule with less than 24 hours' notice, or if I don't attend my appointment. I accept that it is my responsibility to remember my appointments, and that courtesy SMS reminders from Brunswick Health are not guaranteed to be delivered as they depend on telecommunications carriers.
Brunswick Health 1/68 Melville Road, Brunswick West VIC 3055
(03) 9380 8099 | brunswickhealth.com.au
If you have questions about this form or your appointment, please call us.