Before you fill out our new patient registration form, please read our Informed Consent information.
Your Email (required)
Date of birth:
Mobile Number: Home Number:
If referred, what is your doctor's name?
Do you give permission for us to send a letter to your Doctor confirming that you have commenced Treatment? YesNo
How Did You Hear About Us? Online/Google SearchYellow PagesDoctorWebsiteDymocks BuildingReferral
Where Is Your Injury?
List Any Medications You Are Taking
Have you ever taken oral cortisone or prednisone (including asthma medications such as pulmicort, symbicort, flixotide & seretide)? YesNo
Are You Pregnant? YesNo
Are You Trying To Fall Pregnant? YesNo
Do You Wear A Pacemaker? YesNo
Do You Have or Have You Ever Had:
High Blood PressureHeart AttackHeart ProblemsStrokesDiabetesCancerAn aneurysmA pacemakerOsteoporosisRheumatoid arthritisAnkylosing spondylitisPsoriatic arthritisReiter’s arthritisSpinal traumaSpinal traumaSpinal surgeryDislocationsLigament injuriesCartilage injuriesOsteoarthritisDizziness
IF YOU ARE MAKING A CLAIM, PLEASE FILL OUT THE SECTION BELOW
Are you making a claim for this injury?
Workers compensationThird partyVeterans affairMedicare (EPC- Enhanced Primary Care)
For Worker's Compensation Claims, please complete:
Date Of Accident:
Name of Claims Officer:
For Third Party (motor vehicle or accident claims) please complete the below:
Conditions of Treatment I hereby acknowledge and understand that should my claim be rejected in any way that I will be responsible for payment of accounts for any and all physiotherapy services received.
I understand that should I cancel or not attend a scheduled appointment without providing at least 4 hours notice that a cancellation fee of $40.00 will be charged. Not attending an appointment is an inconvenience to the clinic, our other patients, and generally means you require more treatment to recover.
Your “Informed Consent” is required for all treatment provided by this practice. • You may withdraw your consent at any time. Treatment will cease if consent is withdrawn. • If you become uncomfortable with your treatment at any time please inform your physio. • All forms of treatment carry some risk. Risks will be explained prior to treatment at which time you may choose to continue or discontinue treatment.
I give consent for treatment. I agree to this consent remaining valid until such time as I withdraw my consent. I also agree and give consent for my case to be discussed with interested parties. I am fully aware that part of my treatment may include physical “hands on” therapy.