• Your Details

  • Date Format: DD slash MM slash YYYY
  • Referring Health Professional (eg Doctor) Details:

  • Section 2 - Insurer Details

  • PLEASE NOTE: If you have a NSW based insurance provider or you are with NRMA, you may be required to pay our fees privately and seek reimbursement from the insurer.
  • Date Format: MM slash DD slash YYYY
  • PLEASE READ: A claim number from your insurer is provided for processing your claim only and does not indicate that liability has been accepted
  • Drop files here or
    Please attach your letter from the insurer stating that liability has been accepted and that your initial consultation with Sport & Spinal Physiotherapy or Your Podiatry Canberra has been approved
  • Declaration

    PLEASE READ: If you do not provide a letter from the insurer stating that liability has been accepted nor approval for the initial consultation, then you will be required to pay at private rates at the time of your consultation until we receive a letter of liability and approval from the insurer.