Online Registration Form

Online Intake Form

Please Note: We are a Paperless Practice utilising Electronic Health Records. This form will take approximately 5-10 minutes to complete. Several consent and policy forms within the intake will be required to be completed and signed. Please fill them out online at least 24 hours before our visit. All information is Confidential.
Please upload a recent photo of your child, preferably with the expected accompanied parents. The collection, use and storage of the photos is treated by Kids Clinic according to health service providers’ obligations under the Privacy Act 1988. By uploading the photo, you consent to the above terms and conditions.*
Child's Name*

PrefixFirst NameMiddle NameLast Name
DOB*

DayMonthYear
Date
Address*

Unit/House

Street address

SuburbState

Postcode
Carer's Best Email*
example@example.com
Accompanied by:*

MotherFatherCaregiverOther (case worker, support person ....)Other
Mother's Name*

First NameLast Name
Mother's Contact*
Father’s Name

First NameLast Name
Father's Contact
Emergency Name *

First NameLast Name
Emergency Contact*
Referring Family Doctor(GP) or Specialist*
List health professionals involved in the care of your child:*

Family Doctor (GP)PaediatricianSpeech therapistOTPsychologistOthers
Reason for seeing the Paediatrician*

Learning DifficultiesDevelopmental DisorderSpeech DisorderBehavioural problemsSchool IssuesAllergy/Eczema/AsthmaConstipation/Abdominal PainBedwettingBaby/Infant CheckSleep DisorderGrowth issuesObesitySeizures/Abnormal MovementsGeneral Check-upOther
Please indicate any previous diagnosis:*

Speech DelayDevelopmental DelayAsthmaAutism Spectrum DisorderADHD/ODDLearning DifficultiesAnxietyNoneSeizuresAllergyHeart problemsOther
Child attends:*

ChildcarePreschoolSchoolPlaygroupNoneOther
Please name the school
Academic process:

PoorBelow averageAverageAbove averageNot ApplicableOther
Relevant (Related) family history:
Child’s parents:*

MarriedDivorcedSeparatedLiving together
Siblings*
How many?
Pregnancy:

SmoothComplicatedIVF
Method of Delivery
Born at:
Birth weight:
Kg
Tick achieved milestones if your child is less than 6years of age:

WalksClimbsHopsSkipThrowsKicksCatchesStacks blocksThreads beads, uses scissorsGrips pencilSmile sociallyPoints to itemsSleepsTantrumsPretend playsShare playsSpeaks clearlyUses sentencesRepeats SoundsUnderstand instructionsToilet trainedEats independentlyCan dress independently
Diet:
If your child is taking medications please state :*
If "YES" NAME, DOSE AND FREQUENCY OF MEDICATION
Review of symptoms:*

Hearing lossVisual concernsLoud snoringImpulsiveOveractiveShort attention spanFrequent tantrumsSleeping concernsAggressive behaviourPoor social skillsSeizuresAbnormal Movements/TicsNoneOther
Are there any legal/family court proceedings in progress?*

YesNo
Appointment and Cancellation Terms and Conditions:*
Please mark the date of your appointment on your calendar. While we make every effort to remind our clients of appointments by email and phone two or more days prior to the appointment, it is the client's responsibility to maintain his or her schedule. Booking fee up to 100$ will incur when you make your appointment to secure it. Patients who do not attend their scheduled appointment and fail to give a minimum of 48 hours’ notice either by telephone or emailing info@kids-clinic.com.au will lose their booking fee. Extenuating circumstances will be reviewed on a case-by-case basis. Advance notice allows us to better accommodate our clients on the waiting list. Thank you for your cooperation.
Consent to share information:*
I give permission for this information to be shared with other health care specialists and allied health services. I also consent for Dr Sam Nassar and all therapists which my child is receiving therapeutic services from at the Kids Clinic to consult and share information with third parties; which includes but is not limited to FACS, Centrelink and Medicare Australia.
Communication Policy:*
We want to provide you with the best support possible on your child journey, and we endorse transparency and setting expectations up front so we are both on the same page with what we can provide outside of our visits together. This is our Communication Policy:- Questions are not answered on Text Message or Social Media Platforms for legal reasons- Email also poses security risks. If you decide to email us, please give us 1-5 business days to respond. Urgent Questions: call the Office at 02-8404 0567 and leave a message with our management team. We will call you back as soon as possible with an answer. For more Complex questions and new concerns: please book a 10-30 minutes follow-up visit so we can provide you with more appropriate support you deserve
Date

DayMonthYear
Date
Name

First NameLast Name
Signature*

Clear
Should be Empty:

Online Intake Form