Personal Details

Client 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)

Chronic Disease Management (CDM) Plan

Third Party Payment e.g Workers' Compensation


Medical Screening

Medical Screening Questions

Pain Description

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


Consents

Your Consent

Thank you for choosing Esperance Physiotherapy as your health & well-being provider. 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 takes away the opportunity for another client in pain to attend. As a courtesy, we send SMS reminders at 8:00am the day before your scheduled appointment. Tell reception if you would prefer not to receive them; we will switch them off. This will not affect your care. However, if you do not attend or cancel within 24 hours of your scheduled appointment, we will charge a $50 fee

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, yourhealth providerbelieves we can help, they will provide you with a personalised Action Plan. Booking future appointments lets you secure the most convenient treatment time and increases the success of your treatment program.

5. Consent to Treatment: Physiotherapy is generally an effective and safe treatment; however, like any medical intervention, it carries risks. This clinic uses acupuncture/dry needling.Acupuncture/dry needling 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/dry needling is provided to your trunk, there is a possibility of pneumothorax, and your Physiotherapist will seek your consent before this treatment is provided. This clinic uses only single-use, sterile, disposable needles. 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. Please send a confidential email to our practice principal (doug@esperancephysio.com). This is our guarantee to you for not only today's appointment but for all future appointments. Please don't hesitate to tell us where we can improve; we appreciate it.

7. AI & Esperance Physiotherapy. With your consent, we use an AI transcription service called Heidi to transcribe your consultation, so your physiotherapist can spend more time with you and less time typing. Your physiotherapist reviews and edits every transcribed note and remains responsible for its accuracy. Heidi has confirmed to us in writing that audio is never stored, and that transcripts are processed and stored only in Australia and deleted once the note is in your record. You do not have to agree, and you can ask us to stop at any time — including part-way through an appointment. You do not need to give a reason, and it will not affect the care you receive from us. Our Privacy Policy explains this in full and is available at www.esperancephysio.com.

8. Referrals are Appreciated. As a family-owned and operated practice, most of our clients come to us through kind referrals from current clients. This reduces our need to spend money on expensive advertising and lets us focus on what we do best: helping as many people as possible.

We appreciate your kind referrals and support in advance.


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