Private Client

Referral Date

Date of birth*

Gender*

Client Address*

Suburb*

State*

Home phone

Mobile*

Email*

Preferred contact method

GP Name

GP Practice

GP Contact Information

HCP Package level

☐ CDC – Medicare No

Self-Funded

STRC – Agency

CHSP – Agency

HSS – Type

Insurer – Agency

Reason for Referral

To proceed, you must either provide your Medical Diagnosis, upload relevant Medical Documentation, or both.

Diagnosis / PMHX

Attach a Document

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 4.

Smart Solutions Rehab Group is dedicated to protecting the rights of clients. The rights of clients include the right to:

Access healthcare to address their individual needs.
Receive safe, high quality health services that is professional and delivered with skill and competence. Realise their potential for physical, social, emotional and intellectual development.
Be supported to participate in and contribute to social and economic life to the extent of their ability.
Be supported to exercise choice including in relation to takin reasonable risks in pursuit of their goals and planning and delivery of their supports.
Receive open, timely and appropriate communication about their healthcare.
Be respected for their worth and dignity and to live free from abuse, neglect and exploitation.
Be able to determine their own best interests including the right to exercise choice and control to engage as equal partners indecisions that will affect their lives to the full extent of their capacity.
Have their privacy and dignity respected.
Have access to advocates and supports which promote innovation, quality, continuous improvement, contemporary best practice and effectiveness.

Our practice wants you to understand your healthcare rights of access, safety, respect, partnership, information, privacy and feedback.

Email

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New Patient Form