Personal Details

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

3rd Party

Department of Veteran Affairs (DVA)

Enhanced Primary Care Plan (EPCP)

Third Party Payment e.g Workers' Comp or MVA


Medical Screening

Medical Screening Questions

Pain Description

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


Consents

Patient's Consent

Thank you for choosing Esperance Physiotherapy as your provider of health & well-being. We genuinely 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, you must 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 every appointment. This allows for any necessary administrative updates and gives you time to relax before your appointment with your health provider. We will do our best to avoid keeping 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 a 24-hour 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 send SMS reminders at 8:00 am the day before 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 Consultation: All consultation fees are to be paid at the time of consultation.

4.  Your Treatment Action Plan: If, after your appointment today, your health provider believes we can help, they will provide you with a personalised Action Plan. Future booking of appointments allows you to secure the most convenient treatment time, which also increases the success of your treatment program.

5.   Consent to AII & Treatment: To optimise your time with us, an AI program may be used to record and transcribe your session. This allows your Physiotherapist to spend more time with you and less on the computer. Once transcribed and imported into your notes, this recording is deleted. Physiotherapy treatment is generally an effective and safe form of treatment; however, like any medical intervention, there are risks. Acupuncture treatment is used in this clinic. Acupuncture is generally safe, with serious side effects occurring in fewer 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 principal (doug@esperancephysio.com) would be appreciated. This is our guarantee to you for not only today’s appointment but for all future appointments. 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 to us via kind referrals from our current clients. This reduces our need to waste money on expensive advertising and allows us to focus on what we do best: helping as many people as possible.

We appreciate your kind referrals and support in advance.


Draw signature|Type signatureClear