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Patient Registration Form

PATIENT DETAILS

PATIENT CONTACT DETAILS

EMERGENCY CONTACT DETAILS

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DOCTORS NAME

REFERRED BY:

MEDICARE

If you use Alias please write the Alias name & surname

PRIVATE HEALTH INSURANCE

PENSION / HCC/DVA Card

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MEDICAL HISTORY

In order to provide the highest standard of care it is important to have details of your medical history.  We ask that you provide the following information, which will be treated in the strictest confidence.

Have you had or do you now have any of the following? 

PRIVACY, CANCELLATION AND PAYMENT POLICY

Physio on Bayside is committed to maintaining the confidentiality of your personal health information. It is policy of this Practice to maintain the security of personal health information at all times and to ensure that this information is only available to authorised Practitioners. Information may be disclosed to other organisations where required by law or if necessary contact details may be disclosed for debt recovery purposes. 

We have a more comprehensive Privacy Act that you are welcome to read upon request. Please ask our Reception Staff.

We understand that unplanned issues can occur and you may need to cancel an appointment. If so, we respectfully ask for scheduled appointments to be cancelled at least 24 hours in advance. 

Our therapists want to be available for your needs and the needs of others. When a patient does not show up for an appointment, another patient loses an opportunity to be seen. 

Cancellation with less than 24 hours’ notice or failure to attend an appointment will incur a cancellation fee of $35 unless the condition of the cancellation is an emergency. 

As a medical practice, our goal is to provide you with the best possible medical care. As a small business, we strive to be patient friendly and cost effective. This payment policy represents our effort in this area. If you have any questions, please ask.

  • I acknowledge that payment is required on the day of treatment.

  • I acknowledge that in the event of a third-party insurance claim or Medicare plan payment being rejected, I will be responsible for payment of the treatment cost/s.

Physiotherapy treatment is generally an effective and safe form of treatment however like any treatment there are benefits and risks. The purpose of this form is to let you know what your rights are and how we address the issue of collaborative decision making and informed consent between physiotherapist and patient. 

Physiotherapists in this practice will discuss your condition and option for treatment with you so that you are appropriately informed and can make decisions relating to treatment. You may choose to consent to or refuse any form of treatment for any reason including religious or personal grounds. 

Once you have given consent, you may withdraw that consent at any time. 

Please read and sign the following:

Questions of a personal nature

Your physiotherapist may ask personal questions relating to your injury and how your injury impacts on you ‘activities of daily living’. The more information you provide, the more likely it is that the physiotherapist can provide an effective treatment. It is your choice as to what information you choose to provide. If you feel uncomfortable with a particular question or group of questions, please let the physiotherapist know and they will cease.

Physical Contact

During the examination, assessment and treatment it may be necessary for your physiotherapist to make physical contact. Your physiotherapist will ask your permission before making physical contact with you in any way. Wherever possible, withdraw consent at any time at which point, all physical contact with cease immediately. Please inform your physiotherapist if you feel uncomfortable at any time. 

Risks related to treatment

As with all forms of treatment, there are risks and benefits. The physiotherapists will discuss any foreseeable risks with you prior to administrating treatment. In some cases, the physiotherapist may ask you to read information relating to a particular treatment and they may request that you sign a third consent form. This is to ensure that you fully understand any risks involved. 

Children and minors

Consent from a custodial parent is required to treat a minor.

Substituted consent

Where a person is incapable of understanding the risks and benefits of treatment, consent may be provided by another person legally authorised to provide such consent. Evidence of legal authorisation is required in such circumstances. 

You need to let us know

The risk related to some treatments can increase if the physiotherapist is not aware of certain facts. Please inform the physiotherapist if you have:

- A pacemaker or heart condition 

- Suffered from blood clots, thrombosis or stroke

- Suffer from diabetes

- Are currently taking medication

Massage Therapy Informed Consent

I have chosen to consult with and hereby give consent for massage therapy.

I have provided a detailed medical history. I do not expect the therapist to have foreseen any previous or pre-existing condition that I have not mentioned.

I understand that massage may provide benefits for certain conditions but results are not guaranteed. These benefits may include relief of muscular tension, relaxation, reduction in the symptoms of stress-related conditions and provision of general wellbeing.

I also understand that massage therapy may produce side effects such as muscle soreness, mild bruising, increased awareness of areas of pain and light-headedness amongst other possible temporary outcomes.

I am aware that the therapist does not diagnose illnesses, prescribe medications nor physically manipulate the spine or its immediate articulations.

The therapist understands that I have the right to question procedures used and to receive an explanation of any procedures that the therapist performs.

I will tell the therapist about any discomfort I may experience during the therapy session and understand that the therapy will be adjusted accordingly.




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