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 :

• Any private treatment or copayment charges for ACC treatments
• If I fail to attend my appointment or cancel without reasonable notice for physio or 24 hours before for Acupuncture, I may be charged a $45 fee.
• If I fail to pay for my appointment at the time of treatment, I may be charged a statement fee/s and collection costs.
• 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.

I understand that if my treatment is being paid by a third party that the consultant may discuss my treatment with the party involved.

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