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 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.

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