Inform Consent

First Name *

Patient Surname *

Preferred Name

Email *

Date of Birth *

SunMonTueWedThuFriSat

2324252627281234567891011121314151617181920212223242526272829303112345

Address *

Emergency Contact Number *

Mobile Number *

Emergency Contact Name *

Sports/Hobbies

Private Health Fund

Is this a worker’s compensation or third party claim (CTP)?

Claim Number

Insurance Company

Case Manager

Contact details

Were you referred by a GP or specialist?

If yes, by whom?

Are you a memaber of a sports team or gym?

Who is your coach/trainer?

Do you consent to us communicating with your coach/trainer?

How did you hear about us?

Friend/ Family

Facebook

Google

Other

Area of injury/ concern *

Are you pregnant?

Please tick any that are relevant:

Osteoporosis

Diabetes

High or low blood pressure

Heart or vascular conditions (stroke, heart attack, aneurysm)

Recent fracture or bony injury

Implants (medical or otherwise)

Cancer or malignancy

Major surgery

Congenital condition

Arthritis (Osteo, Rheumatoid, ankylosing spondylitis)

Prolonged use of steroids, oral cortisone or prednisone

Please detail any of the above

Other current or past medical conditions?

Do you consent to hands-on treatment as part of your session, understanding that some tests and techniques may cause discomfort? *

Are you comfortable providing consent for the possibility that, during the session, some articles of clothing may need to be removed for specific assessments or treatments? *

It is my responsibility to tell the therapist if I am feeling uncomfortable in any way *

Yes

It is my responsibility to inform the therapist of any medical conditions that may affect treatment *

Yes

I must give 24 hours notice of cancellation of my appointment; Otherwise, a cancellation fee equivalent to the price of the session booked will be charged. The cancellation fee should be paid within 24 hours of booking the session and can be paid by phone ID at 0434842378. *

Yes

Signed *

Date *

SunMonTueWedThuFriSat

2324252627281234567891011121314151617181920212223242526272829303112345