Prior to your appointment

Once you have rung PHYSIOSOUTH to make an appointment - please complete and submit this form
and we will have them ready for your appointment. 

If you haven't made an appointment please call (03) 3326487 or use our request an appointment page on this website then return to this page and complete all questions.

Please select which PHYSIOSOUTH clinic have you made your appointment at?

*required

Consent for treatment

Full Name:              *required
Address *required      Post Code    
Phone                     
         Home                           Work                                   Mobile
 
Email:  *required  
Date of Birth *required  
Occupation  
Usual Doctor  
Accident at Work ?                    if yes please answer question below
    Yes           No
 
Employer       
               Name                                           Address                                       Phone
 
Who referred you    

 
 
 For your safety and our information please answer the following questions
 YES/NO

Do you have any specific cultural needs we need to be aware of?
*required
 
Do you wear a hearing aid or pacemaker?
*required
 
Do you have any artificial implants eg joint replacements , metal screws?                    
*required
 
Do you have AIDS or Hepatitis?
*required
 
Are you pregnant?                      
 *required
 
Are you on any long term medication?                         
*required
 
Have you had recent or major surgery?                  
*required
 
Any chronic or serious health problems, Epilepsy, Diabetes, Asthma, Heart problems? 
*required
Comments                                         
 
Please list 3 activities that your current injury is preventing you from doing i.e. lifting,  sleeping etc and then rate them 

0
is unable to perform activity to same level as before injury
10 is able to perform activity at the same level as before injury 
1       * required  
2       * required  
3       * required  
 
Please rate your level of pain you are experiencing today due to your injury
 
0 being NO  pain                    10 being EXTREME pain     * required
 

  

Consent for treatment

 
I hereby give my consent for Physiotherapy treatment bearing in mind that a full verbal explanation will be given at the time of treatment and that I can decline treatment at any time. I also give consent for the sharing of information with relevant practitioners involved in my treatment at PHYSIOSOUTH.

I undertake to pay for all treatment charges & material costs and pay for any treatment declined by ACC. I understand that I am liable for any recovery costs required on my account and that after a thirty-day period, there would be a statement charge for every statement I receive.

I understand that if I fail to attend an appointment without contacting PHYSIOSOUTH there will be a $30 non attendance fee or if I cancel without giving at least 6 hours notice I will be liable for a $20 late cancellation fee
 
 Consent given                    
   
     
 
 


In accordance with the Privacy Act, all information recorded in your health records will be kept confidential. Your records will only be accessed by the physiotherapist and staff providing your care and service. All personnel in this practice are bound to maintain strict patient confidentiality. Under the privacy act, you have the right to access to and correction of your personal information held by this practice. No information will be given to a third party without your written permission

 
 
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