New Patient Registration Form

PATIENT DETAILS

PATIENT CONTACT DETAILS

EMERGENCY CONTACT DETAILS

REFERRING DOCTOR TO US (SKIP IF NOT-APPLICABLE)

PRIVATE HEALTH INSURANCE

WORKERS COMPENSATION & THIRD PARTY INSURANCE DETAILS (SKIP IF NON-APPLICABLE)

NDIS CLIENTS

PENSION / HCC/DVA Card (IF APPLICABLE)

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CASE HISTORY

HOW DID YOU HEAR ABOUT US

INFORMED CONSENT

Australia is a genuinely multi-cultural society.  Do you have any cultural needs with respect to your treatment? 

Your Personal Health Information and your Health Record may be collected, used and disclosed for the following reasons:

For communicating with other treating medical professionals, for follow-up/reminder calls, for discussion with third party insurers, accounting/Medicare/health insurance procedures, disease notification as required by law, for use by all practitioners in this practice when consulting with you and for legal disclosure as required by a court of law.

If you have any concerns or wish to restrict access to your information please discuss these with your practitioner or receptionist.


Your “Informed Consent of treatment” is required for all treatment provided by this practice.

  • A patient may be expected to remove certain articles of clothing to allow for a detailed musculoskeletal assessment.

  • A patient is entitled to bring a chaperone if they so wish to

  • You may withdraw your consent at any time. Treatment will cease if consent is withdrawn.

  • If you become uncomfortable with your treatment at any time please inform your practitioner.

  • All forms of treatment carry some risk. Risks will be explained prior to treatment at which time you may choose to continue or discontinue treatment.

Liability: Hyperwell Health & Performance and Bodyfocus Physiotherapy accepts no responsibility for the treatment received. Any professional liability is between the patient and the individual therapist.[All Hyperwell Health & Performance and Bodyfocus Physiotherapy practitioners are insured through their respective insurance companies]. Hyperwell Health & Performanceand Bodyfocus Physiotherapy adopts assurance protocols in accordance with the clinical guidelines as are specified by the APA, CAA or relevant professional association.


IMPORTANT CANCELLATION POLICY

We really value time – both yours, and ours. Running an efficient practice allows us to provide service to more people, and gives us time to pursue research and educational roles in the field. Our cancellation policy supports and respects the time commitment of our clients and our physiotherapists, and is intended to make our expectations clear.


We require a minimum of 24 hours notice if you wish to cancel your appointment. This provides the practice with an opportunity to offer the appointment to other clients from our waiting list.


If you do fail to attend or cancel your appointment without providing a minimum of 24 hour notice, you will be charged a fee of equivalent to 50% of the consultation fee.

By signing this document you agree to our cancellation policy.

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