Rehabilitation Membership Request

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Rehabilitation Membership Request form

Client Details

First Name *

Surname *

Address *

Phone *

Email *

Date of Birth *

Claim Number *

Membership

Preferred Facility *

Cannington Leisureplex Riverton Leisureplex

Client agrees to the Membership Terms and Conditions

Yes No

Read Membership Terms and Conditions

Membership Type *

3 Month – Wellness Suite, Gym, Group Fitness and Swimming – $450 (written clearance must be provided for clients to attend Group Fitness classes) 10 Entry – Riverton Leisureplex Wellness Suite and Swimming (valid for 12 months) – $121.50^ 10 Entry – Cannington Leisureplex Wellness Suite and Swimming (valid for 12 months) – $103.50^

Prices valid to 30 June 2025.
^ Physio entry extra charge applicable.

I authorise payment will be made on behalf of the client * *

Yes No

Provider (referral company)

Provider Company Name *

Provider Contact Name *

Provider Email Address *

Provider Phone *

Insurance Company

Insurance Company *

Insurance Contact *

Insurance Phone *

Accounts Payable Contact *

Accounts Payable Contact Email *

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