Registration Form - AdultPlease complete all fields below prior to your appointment. Date of enquiry * MM DD YYYY Client name * First Name Last Name DOB: Mobile * Country (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Do you have NDIS funding? Yes No Do you have an Enhanced Primary Care Plan? Yes No Were you referred to this service? Yes No Please check show you agree with the following: Payment for services is via credit card or direct debit (see payment form attached to confirmation email). Payment for services will be processed on the day of the session and a receipt forwarded to the email address provided. If payment is not received for whatever reason, future sessions will be cancelled. If I am late for an appointment, the appointment will conclude at the time that was planned, and I will still incur the full fee for that consultation Cancellations within 24 hours will incur a 50% cancellation fee. Message for Dr Kylie Smith: Signature Thank you!
