Online Patient Information Form

Patient Information Form

Fields marked with an * are required

We are committed to providing our patients with the best care. To do this it is essential that your record is kept up to date and accurate.

PATIENT BACKGROUND

Australia is a genuinely multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds.


PATIENT CONSENT

I understand cancelling a physiotherapy treatment session within 24 hours of the appointment will incur the total cost of that session.

I give permission for my physiotherapy records and personal information to be shared between physiotherapists of this practice. I understand that all physiotherapists and staff of this practice are covered by confidentiality agreements. I also understand that should I not want my physiotherapy or personal information disclosed to other physiotherapists or staff of this practice I need to inform my usual physiotherapist of this issue.

I agree to allow my physiotherapist to communicate relevant physiotherapy details to GPs, Specialist Doctors, Hospital Medical Staff, Medical Imaging centres (e.g. X-ray, MRI scan, CT scan) and other Health Care Providers (e.g. Podiatrists) involved in my physiotherapy care.

I understand that my account can be held up to 14 days until I have given all the claim details above. If my claim has been denied or the above claim details have not been given within 14 days, I am responsible for the payment of my account.

I understand cancelling a physiotherapy treatment session within 24 hours of the appointment will incur the total cost of that session. This will be billed to me personally, not to the insurance company.

Please sign the form on your first visit to the Gym.