Book

Appointment

Introduction

You have requested to enrol as a patient and to receive treatment at Every Green Clinics Australia Pty Ltd.

This Patient Registration and Consent Form provides you with information about what your treatment may involve, including information about our services which may be prescribed to you if it is clinically appropriate.

Please read this information carefully and ask questions about anything that you do not understand or want to know more about.

Declaration

After reading this Patient Registration and Consent Form, you will be asked to sign the declaration and consent section.

By signing it you are telling us that you:

Understand what you have read.
Consent to the use of your personal and health information as described here and in our Privacy Policy.
Agree to comply with the terms and conditions specified in this Patient Registration and Consent Form and our Terms of Use.

If you do not want to proceed with your patient enrolment or treatment after reading this Patient Registration and Consent Form, or at any time, please let us know as soon as possible.
You will be given a copy of this Patient Registration and Consent Form for your records.

Select Title

First Name *

Last Name *

Select Gender *

Date of Birth *

Mobile Phone *

Email Address *

Medicare Number

Medicare IRN

Expiry Month

Expiry Year

About Every Green Clinics

Every Green Clinics works with a number of Australian registered medical practitioners who specialize in treating patients with a variety of medical conditions using mainstream and integrative health approaches.

What do I have to do?

You have requested to enrol as a patient and to receive treatment at Every Green Clinics Pty Ltd.
Every Green Clinics provides its services, including arranging patient consultations, through its website.
By signing this Patient Registration and Consent Form you agree to comply with the Terms of Use of Every Green Clinics’ website and online account system.
A copy of our Terms of Use is available here: https://everygreenclinics.com.au/terms-and- conditions/

What will happen to information about me?

Every Green Clinics and its medical practitioners will collect your personal information, including some health information, in order to provide you with patient services and treatment. We will not disclose your information without your consent unless it is required or permitted by law. How we collect, use and disclose your personal information is described in more detail in our Privacy Policy.
A copy of our Privacy Policy is available here: https://everygreenclinics.com.au/privacy-policy/
By signing this Patient Registration and Consent Form you consent to Every Green Clinics collecting and using personal information and health information about you in accordance with our Privacy Policy.

Questions

If you have any questions about this Patient Registration and Consent Form you can contact Every Green Clinics at info@everygreenclinics.com.au.

Declarations and Concent

- I have read this Patient Registration and Consent Form or someone has read it to me in a language that I understand. - I have had an opportunity to ask questions and I am satisfied with the answers I have received.
- I freely agree to be a patient of Every Green Clinics as described and understand that I am free to withdraw my consent at any time.
- I understand that I will be given a signed copy of this document to keep.

Signature of Patient / Substitute Decision Maker *

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Authority of Substitute Decision Maker (if applicable)

Authority of Substitute Decision Maker

Date

Book

Appointment

Introduction

Declaration

Call Now

Email

ABN Number