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Consent form

Title

Name

Preferred name

Address

Preferred location for treatment

A
B
C

Phone (Mobile Preferred)

Email

Date of birth

Ethnicity

Occupation

Employment type

Business / Employers name and address

Work intensity

Medical centre & GPs name

ACC info - if you already have an ACC number please enter the claim number below

How did you find Movewell Physio?

For your safety and protection, and for our information, please answer the following questions below that apply to you. Only tick if it applies to you. Do you have any of the following conditions?

Pregnant

A

Physical Disability

A

Diabetes

A

Heart Problems

A

Skin Condition

A

Artificial Implants

A

Allergy

A

Other relevant medical history

Medication

Recent/previous surgery

Have you had any previous radiography investigation (eg X-ray, US, MRI)?

A
B

If yes - please specify

In accordance with the Privacy Act, all information recorded in your files will be kept confidential. Your record will only be accessed by the practitioner / instructor providing your care & those office staff responsible for filing. All personnel in this practice are bound to maintain strict patient confidentiality. Under the Privacy Act, you have the right of access to, and correction of, your personal information. No information will be given to a third party without your consent. If you have any concerns or complaints about your treatment you may approach any staff member to discuss your concerns. We’re here to help and have policies in place that will deal with your complaint promptly and fairly. You may also request a complaints form from reception.

Informed consent

I hereby consent to assessment/treatment for the purpose of providing physiotherapy or podiatry services as may be necessary in support of my illness, injury or condition. I understand that a full explanation will be given prior to assessment/ treatment. I understand I have the right to decline part or all of my treatment being offered. I understand my right to a second opinion and right to have a support person for all appointments.

Yes, I am aware that there are surcharges and that I am to make payment at the end of each treatment session. If you are unable to make your appointment, we respectfully ask that you notify our clinic at least 12-24 hours in advance by txt email or phone. Failure to cancel an appointment or no show's may incur a non-attendance fee of $55.00 at our discretion.

A

If under 16, must be signed by parent/guardian. Please state the parent/guardians full name.

E-Signature

Sign here