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Insurance Form Clinic4Sport
Please complete this form before your first appointment.
The information provided will be used to verify your insurance cover and authorisation for treatment.
* Indicates required question
Email
*
Record my email address with my response
Full Name
*
Your answer
Date Of Birth
*
MM
/
DD
/
YYYY
Mobile Number
*
Your answer
Email Address
*
Your answer
Home Address
*
Your answer
Insurance Provider
*
Your answer
Membership Number
*
Your answer
Authorisation Code
*
Your answer
Number Of Sessions Approved
*
Your answer
Short Synopsis Of Injury
*
Your answer
Declaration
*
I confirm that the information provided above is accurate and complete.
Required
Payment Undertaking
*
I agree that I am personally responsible for any treatment charges not paid by my insurer for any reason, including insufficient authorisation, policy exclusions, exhausted benefits, excesses, or declined claims.
Required
Electronic Signature
*
Your answer
Date Signed
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to .
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