WorkCover Client Information

By sending this form through you are acknowledge the following:

LifeWise cancellation requires a minimum of 24 hours notice of cancellations.
$120 fee applies for late cancels within the 24 hour period and any non-attendance. This is payable by the client as it is not covered by the WorkCover Insurer.
Your Psychologist is required to liaise regularly with your Insurance Agency and their representatives as part of the WorkCover process.

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone

Medicare Number

Your Number on the Medicare Card

Medicare Expiry Date

Occupation

GP and Surgery you attend:

Please send a copy of your GP referral and any other paperwork they have provided.

Do you Identify as Aboriginal and Torres Straight Islander?

I give permission for LifeWise to liaise with me via SMS and email

Emergency Contact

Name and contact number of the person who you would like contacted in the event of an emergency

Additional Consent to contact

Name and contact numbers of any other persons who you give consent for LifeWise to liaise with regarding your appointments including Insurance related specialists and other health care providers in addition to those directed by your Insurance Agency.

Known illnesses/Disorders

Any additional information:

If you need any other assistance in the interim please contact Steph Baker our Practice Manager on 49320432 or via email to admin@lifewise.com.au. Many thanks for your assistance.

Contact us.

admin@lifewise.com.au

(02) 4932 0432 - Maitland

(02) 4948 1226 - Warners Bay

General enquiry

NDIS enquiry