Download Patient Consent Form and what to expect here or fill out our online form. Hogan Osteo Plus Consent Form Full name:* First Last If you are known by any other names please state:Address:* Street Address City ZIP / Postal Code Please provide a recent previous address iIf applicable OR Next Of Kin contact details:* Street Address City ZIP / Postal Code Email: Date Of Birth:* DD MM YYYY I am 15 years or over*YesNoName of Parent/Guardian/Caregiver filling in form on your behalf:* First Last Please select preferred Method To Receive Appointment Reminders and fill in details:*EmailHome phoneWork phoneMobileMobile (text only)Mobile text only*Mobile*Home Phone*Work Phone*Email* GP*How did you hear about us?Friends or familyReferralGoogleSocial MediaNameNameOccupationTerms and Conditions* To the best of my knowledge the information I have provided is accurate and true: I confirm that I have read and understood “What to Expect” and consent to being treated in the manner described.I confirm that I am responsible for payment of fees. I understand I will be charged a $40.00 cancellation fee for Osteopathic or Massage Treatment if I fail to notify Hogan Osteo Plus within 24 hours that I cannot attend my appointment or fail to make my appointment.I am aware that debt collection fees may be charged if I fail to pay my account in a timely manner.If my practitioner becomes unavailable at short notice due to sickness or unforeseeable circumstances I am happy for my appointment to be rescheduled or to see another practitioner.I understand that my personal medical information will be held confidentially at the premises of Hogan Osteo Plus. A report on my treatment, condition, progress, diagnosis may be forward to my General Practitioner, surgeon, ACC or other provider as requested. I consent to my NHI number being accessed for medical purposes so that investigation results can be electronically transmitted.NameThis field is for validation purposes and should be left unchanged.
