Street number and name
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.
I understand that I am liable to pay for :
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.
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:
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
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