Patient Information Form

Please complete this patient information form and payment details and we will be in touch to confirm your details and book your appointment.

First Name(required)

Surname Name(required)

Gender(required)

Date of Birth(required)

Email(required)

Phone Number (required for Telehealth)(required)

Emergency Contact Name and Phone Number (or next of kin)(required)

Rebate

Please select relevant rebate method(required) Private Health Fund

Medicare Rebate (GP Mental Health Plan required)

Bulk Billed (GP Mental Health Plan for Centrelink Health Care Card holders only)

Department of Veterans Affairs (DVA) and Open Arms Sponsorship

Date of Mental Health Plan (if applicable)

Doctor's Provider Number (on Mental Health Plan)

Referring Doctor's Name

Medicare Number(required)

Individual Reference Number (IRN) on Medicare Card (required)

Medicare Card Expiry Date (required)

DVA Card Number / Colour(required)

Would you prefer a Face to Face or Online appointment?

Select preferred assessment type:(required) Face-to-Face

Telehealth (Phone)

Zoom Video Conference

Skype Video Conference

Face Time Video Conference

Consent Contract

By submitting your information, you're giving us permission to contact you to confirm or make an appointment and you agree to pay all costs in relation to the services fees if applicable. All payments are to be to your appointment. Your information is not shared with any other organisation or company outside of Access Psychology, unless your consent is given to communicate with above mentioned remuneration organisations.

If you are in crisis or danger, please DO NOT USE THIS SITE. Please call 000 on your phone.

ACCESS PSYCHOLOGY

Lvl 4, Suite 14-15 PARKRISE
3 Alison Street
Surfers Paradise, QLD 4217
Australia
E: hello.accesspsychology@gmail.com
Ph: 07 5592 4879

OPENING HOURS

Monday – Friday 8am – 4pm.
Call us to make an appointment,
or click here to send us your details and we will be in touch.

ACCESS PSYCHOLOGY,