Online Client Application: Chronic Care/EPC Medicare Clients Your DetailsName* First Last Address* Street Address Address Line 2 City State Postcode Mobile*Work PhoneEmail* Enter Email Confirm Email Date of Birth* Date Format: DD slash MM slash YYYY Referring Health Professional (eg Doctor) Details:Referring Health Professional Name:*Referring Health Professional Address* Street Address Address Line 2 City State Posrcode Referring Health Professional Email Please attach your Medicare Referral Form*The referral form must be titled Referral form for Individual Allied Health Services under Medicare for patients with a chronic medical condition and complex care needs. An example of the form can be found herePlease confirm your form states the following information:* Select All Your GP name, address and provider number Addressed to Sport & Spinal Physiotherapy or Your Podiatry Canberra States the number of services for each type of Allied Health Service Signed and dated by your GP Please note: If any of the above details are missing from your form, you will need to return to your GP to amend your formDeclarationI understand and acknowledge that:* The above information is true to the best of my knowledge I will at all times be responsible for payment of my account in full I will need to provide payment of my account in full at private rates at the time of consultation until I have provided all of the information and documents required CAPTCHA