Child's Details *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Gender

Male

Female

Mother/Guardian Details *

First Name

Last Name

Father/Guardian Details

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

GP Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Paediatrician Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Terms and Conditions (Please check to indicate you have read and accept these terms) *

I understand that payment for consultations are due on the day of treatment. If payment is not made in full, I understand that an account keeping fee of $5 per 30 day period may be applied until the account is fully paid.

I understand that an SMS reminder is only a reminder and not confirmation of my appointment. Failure to receive an SMS is not an acceptable reason for cancellation. I understand that in the event of a cancellation 24hrs notice is required, or a fee of 50% of the consultation fee will be charged.

Health Information (Please check to indicate you have read and accept these terms) *

Information about your medical and family health history is needed to provide accurate diagnoses and appropriate treatment. Some information about you is also provided to Medicare and private health funds if relevant, for billing and medical rebate purposes. You have the right to access your information.

Under the Privacy Guidelines, the right of children to privacy of their health information based on the professional judgment of the chiropractor and consistent with the law, might at times restrict access to this information by parents or guardians

Research Information (Please check your option) *

Data collected Chiropractic Children's Healthcare may be used for research purposes. All data, if used for this purpose, will be de-identified prior to public release to maintain your privacy. By signing this document, you agree to the collection, storage and use of health information for research purposes. If you do not wish to be a part of the research conducted by Chiropractic Children's Healthcare, you may choose to "opt-out" at any time. This will not influence any

Agree to the collection and use of de-identified data for research purposes.

I choose to opt out.