Patient Details Title: MxDrMrMrsMsMiss Date of Birth: Medicare Number Patient Number Expiry Private Health Insurance Do you have Private Health Insurance? YesNo Notifications Do you wish to receive relevant reminders by SMS YesNo Do you wish to be emailed relevant information? YesNo Emergency Contact Referral GP or Surgeon Details GPSpecialistSports ClubOtherNo Referrer Workers Compensation Third Party / Compulsory Third Party (CTP) Insurance Is your visit related to a Workers Compensation or Compulsory Third Party Insurance claim? YesNo YesNo Referral letter from nominated treating doctor (NTD) YesNo Letter from insurance company “accepting liability” YesNo WC Medical Certificate of Capacity Yes I understand that failure to provide these documents will mean treating patient will need to pay for any treatment until documents have been provided Patient Background Australia is a genuinely multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds. Do you identify as someone from a culturally and/or linguistically diverse background? NoYes To assist with health initiatives – are you an Aboriginal or Torres Strait Islander? NoYes - Torres Strait IslanderYes - AboriginalYes - Aboriginal & Torres Strait Islander Patient Consent Yes 24 Hour Cancellation Policy I understand cancelling a physiotherapy treatment session within 24 hours of the appointment will incur the total cost of that session. Yes Use of personal health information within the Practice 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. Yes Use of personal health information outside the Practice: 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. This practice from time to time participates in physiotherapy research projects with outside organisations. We stress that all information shared is depersonalised (i.e. names of patients are not given). Yes Workers Compensation / CTP: 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. Yes For Dependant: As Parent/Guardian of , I authorise that their health information be also used in the above mentioned manner. How did you hear about PhysioGym? GPSpecialistSports ClubInternetFriendNewspaperLetterbox DropOther Your Signature
