Online Form

1. Client Consent and Information Form

Please fill out the form below. You must fill in the red fields.

CONSENTS

I hereby agree to consent to treatment by an appropriately qualified Physiotherapist for the purpose for providing comprehensive physiotherapy services as may be necessary in support of my illness, injury or condition. I have been given the opportunity to read clinic information prior to treatment. I understand I have the right to decline part or all of the treatment being offered. I understand my right to a second opinion.

AGREEMENT TO PAY

I understand that I am liable to pay for :

Any private treatment or copayment charges for ACC treatments
If I fail to attend my appointment or cancel without reasonable notice I may be charged a fee of $
If I fail to pay for my appointment at the time of treatment I may be charged an account administration fee.
Any treatment that is declined by ACC or other funder
The costs of materials such as orthotics, materials, products etc

I understand that if this service requires to engage a Debt Recovery Service to recover my debt, I will be liable for any recovery fees.

GUARDIAN FORM

I accept full responsibly for any outstanding accounts incurred for treatment, products and or collection costs. And agree to the terms as per treatment to consent form completed for my dependent specified above. My details are:

Name

Legal parent/Guardian for

Address:

Phone number:

DOB

CONSENT TO RELEASE INFORMATION TO A 3rd PARTY

I consent to the disclosure of my records to any person/organisation necessary for the effective management of my condition.
I consent to a discharge/update report being sent to my doctor or medical centre

I have read and understand the information above.

Use the stylus to sign below

SIGNED:

(If under 16 must be signed by parent/guardian) DATED: 20/01/2021