Client Information and Consent Form

Name *

First

Last

Date of Birth *

Contact Number (mobile preferred) *

Email Address *

Medicare Number and Patient (IRN) Number *

Home Address *

Your Doctor's name *

Your Doctor's clinic *

Emergency Contact Person *

Emergency Contact Number *

Please tick any of the following that apply to you

I have private health with extras cover
I have a Department of Veterans Affairs (DVA) Card
I have a Worksafe/Workcover claim number
My doctor has placed me on a Medicare EPC/CDM plan
My treatment will be part of a NDIS service agreement
I have been referred by my GP/Specialist/Other health professional
You will need to invoice a 3rd party for my treatment

For Worksafe/Workcover - please provide your claim number and Insurer

For NDIS - please provide your plan number and plan manager (if applicable)

If you have a DVA card - please provide your DVA number

CONSENT AGREEMENT: It is part of our duty that all physiotherapists inform you of any possible risks associated with professional treatment techniques utilised during a hands-on treatment session. Some therapy techniques such as therapeutic massage, joint manipulations, traction/distraction or mobilisations have a minute risk of causing injury. Injury may be caused to structures including, but not limited to; nerves, bones, muscles, ligaments, intervertebral discs or arteries. The use of tape or massage mediums may cause irritations or allergic reactions on the skin of some individuals. Where possible, hypoallergenic tapes and massage mediums will be used to further reduce the risk of this occurring. Superficial Dry Needling and the use of acupuncture needles, along with the aforementioned techniques can occasionally cause localised swelling, bruising, or transitory increased in the levels or distribution of pain or other symptoms. You may choose to consent or refuse any form of treatment for any reason including religious or personal reasons. Once you have given consent, you may withdraw that consent at any time *

I have read this form, understand the information it contains and give my consent to receive treatment.

Comment

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