PATIENT REGISTRATION FORM

If applicable, please provide the following information:

IF YOU ARE UNDER 18 YEARS OF AGE

Private/Corporate Patients:

I agree to pay all reasonable fees/charges incurred by the Vitalis Physiotherapy for goods and services provided for me including overdue account fees, booking fees and debt collection costs.

I authorise Vitalis Physiotherapy to disclose my personal information in relation to my health condition to any other health practitioner who is providing me with health care services or items.

Workers Compensation, Motor Vehicle & DVA Claims:

I agree that in the event of non-payment of my account by my employer/insurer/DVA/Medicare that I will be held responsible for all reasonable fees/charges incurred by the Vitalis Physiotherapy for goods and services provided including overdue accounts fees and debt collection costs.

I authorise Vitalis Physiotherapy to disclose to my employer/employer’s insurance company, Work Cover Queensland, DVA and/or any other health practitioner who is providing me with health care services or items, any information in relation to my condition for which I have a claim.

In the event of the claim being rejected, the patient will be held responsible for all reasonable fees/charges incurred by Vitalis Physiotherapy for goods and services provided.

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PATIENT REGISTRATION FORM

Physiotherapist in this practice will discuss your condition and options for treatment with you so that you are informed and can make decisions regarding your treatment. You may choose to consent 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.

Questions of a Personal Nature

Your Physiotherapist may ask personal questions relating to your injury and how your injury impacts on your ‘activities of daily living’. The more information you provide, the more likely it is that the physiotherapist can provide effective treatment. It is your choice as to what information you choose to provide.

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. Physical contact requires your express consent. You may withdraw consent at any time at which point, all physical contact will cease immediately. Please inform your physiotherapist if you feel uncomfortable at any time.

Risk related to treatment

Physiotherapy is an effective and safe form of treatment. However, if there are any risks associated with the treatment, your therapist will clearly state them and discuss them with you.

Children, minors and Substituted Consent

Consent from a custodial parent is required to treat a minor. Where a person is incapable of understanding the risks and benefits of treatment, consent may be provided by another person legally authorized to provide such consent. Evidence of legal authorization is required in such circumstances.

You need to let us know when:
- a pacemaker or heart condition
- suffered from blood clots, thrombosis or stroke
- suffer from diabetes
- are currently taking regular medication

Booking appointments

Your therapist will outline a treatment plan as the best plan for your recovery. You will achieve the maximum results when you follow your recommended treatment plan. To be consistent we ask that you schedule your appointments in advance.

WE HAVE 24 HOUR CANCELLATION POLICY
FULL CONSULTATION FEE APPLIES FOR LATE CANCELLATIONS/NO SHOWS

The practice’s system will send you a reminder message the day before to the mobile phone that has been nominated.

24 hours notice is required to cancel or change appointments as we have a long waiting list. If you do not attend an appointment without giving us appropriate notice, full consultation fees will apply.

Consideration will be given for unavoidable circumstances. People who repeatedly miss or reschedule appointments will regretfully be discharged from care.

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PHYSIOTHERAPY CONFIDENTIAL PATIENT CASE HISTORY

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