Client Details Form

Personal Details

Details may include; ** Name of GP/Specialist that referred you ** Your family/friend's name that referred you (so we can send a thank you gift) ** What website you searched

Department of Veteran Affairs (DVA)

Enhanced Primary Care Plan (EPCP)

Third Party Payment e.g Workers' Comp or MVA

Medical Screening Questions

Pain Description

Where 0 is no pain and 10 is the worse pain you can imagine.

Patient's Consent

Thank you for choosing Esperance Physiotherapy as your health & well-being provider. We truly appreciate your support and will do our absolute best to provide you with exceptional healthcare solutions for many years to come.

To ensure we provide you with the best possible care, it is important that you understand and agree to our terms and conditions as outlined below:

1. Be on Time: All clients are expected to arrive 5-10 minutes early for each and every appointment. This allows for any updates and gives you time to relax before seeing your health provider. We will do our absolute best to not keep you waiting.

2. Cancellation Policy & SMS Reminders: We are a busy clinic, so if for some reason you need to move or cancel future appointments, we require 24-hours notice. Failure to attend an appointment disrupts your treatment progress and also takes away the opportunity for another client in pain to attend. As a courtesy service, we do send SMS reminders @ 8.00 am the day prior to your scheduled appointment, however, if you do not attend or cancel within 24 hours of a scheduled appointment, a fee of $50 will be charged.

3.  Pay at the Time of Consult: All consultation fees are to be paid at the time of consultation.

4.  Your Treatment Plan: If after your appointment today your health provider believes we can help they will outline a course of treatment. The future booking of appointments allows you to secure the most convenient treatment time for you and also increases the success of your treatment program.

5.  Consent to Treatment: Physiotherapy treatment is generally an effective and safe form of treatment however like any intervention there are risks. Acupuncture treatment is used in this clinic. Acupuncture is generally safe with serious side effects of less than one per 10,000 treatments. Common side effects include drowsiness, minor bleeding (2%), pain after treatment (2%) and fainting (2%). If acupuncture is provided to your trunk there is a possibility of pneumothorax and your Physiotherapist will seek your consent before this treatment is provided. Single-use, sterile, disposable needles are only used in this clinic. Allergic skin reactions to massage oils or strapping tapes are possible. Electro-physical agents such as ultrasound have been linked to minor burns.

6. Guarantee: If for some reason, we did not live up to your expectations today, it would be great for you to tell us. A confidential email to our practice principals (doug@esperancephysio.com or melissa@esperancephyio.com) would be appreciated. This is our guarantee to you for not only today’s appointment but for any appointments in the future. Please do not feel bad about telling us where we can improve, it is appreciated.

7. Referrals are Appreciated. As we are a family-owned and operated practice, the majority of our clients come via the kind referrals from our current clients. This reduces our need to waste money on expensive advertising and concentrate on what we do best, helping as many people as possible.

We thank you in advance for your kind referrals and support.


Draw signature|Type signatureClear