Rehabilitation Membership Request

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Prices and memberships

Cannington and Riverton Wellness Suites closed for refurbishment from February 2025.

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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 – Gym, Group Fitness and Swimming – $450 (written clearance must be provided for clients to attend Group Fitness classes)

Prices valid until July 2026. Physiotherapists receive free entry alongside their client, with proof of employment as an active Allied Health Professional (AHP).

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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