Patient Consent Form

Please confirm your details and provide consent for treatment

Import Patient Data

📋 Copy & Paste from Halaxy

Steps: 1) Go to Halaxy patient page 2) Press Ctrl+A to select all 3) Press Ctrl+C to copy 4) Paste below

💡 Tip: Works with any Halaxy patient profile page - just copy the entire page and paste here!

Patient Details Confirmation

First Name *

Last Name *

Date of Birth *

Email Address

Phone Number *

Address

Emergency Contact (Name & Phone)

Treatment Consent

Cancellation Policy

6+ hours notice required for cancellations/reschedules
Less than 6 hours notice or no-shows incur full appointment fee
Cancellation fees are not covered by Medicare, private health funds, DVA, or WorkCover

Cancel by: • Phone: 4661 7756
• SMS: Reply "NO" to appointment reminder

I have read and understood the above information, consent to treatment, and agree to the cancellation policy. I confirm that the details I have provided are correct.

Digital Signature

Please sign below to confirm your consent:

Date *

Patient Name (Print) *