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Private Referral From

Thank you for making your first appointment with Bluey Mobile Health Group. This form is intended for anyone wishing to refer Private clients.

If you would like help filling out either form, please call 1800 941 223 or use the Live Chat function for assistance.

Click or drag a file to this area to upload.
Please upload relevant documents (Please include any risk assessments, EPC/CDM form if available)
I have read the above information and understand the reasons Bluey Mobile Health Group collect my personal information and how it is used. I know that it is my choice what information I provide. However, I also understand that withholding information may be detrimental to my treatment. I understand there may be a need to collect further information from other sources, such as radiography reports and/or medical reports. I am aware that I can access and/or correct my personal and treatment information on request. I understand I am financially responsible for any balance due on my account. I consent to podiatry treatment being undertaken by the podiatrist. I understand that Bluey Mobile Health Group will explain all treatments before being administered. I understand I can verbally withdraw consent at any time.
There is now a legal requirement that we gain your consent to collect and use personal information about you. Please read the following carefully and sign the declaration if you consent to Bluey Mobile Health Group to collect this information. In order to assess, diagnose, and treat you, Bluey Mobile Health Group needs to collect some personal and medical information from you. We may also use this information for: The administrative purposes of running the practice. Billing, either directly or through a third party. Use within the organisation when giving information to other clinical staff for your ongoing treatment and care. Disclosure of treatment and medical information to your or other clinical treatment providers.

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