Personal Details

Client Form

Personal Details

Title

Sex

Gender

Date *

First Name - Legal *

First Name - Preferred *

Last Name *

Date of Birth *

Email *

Mobile Phone (for SMS Reminders)

Would you like to receive our monthly Health & Wellbeing Newsletter? *

Yes Healthy News UpdatesNo Healthy News Updates

Home Address *

City *

State *

Postcode *

Home Phone

Occupation

Family Doctor

Emergency Contact Person

Emergency Contact Phone Number

How did you come to attend Esperance Physiotherapy? *

Other - More detailsDetails 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

What is the main thing you would like to achieve from today's appointment? *

Have you seen another therapist recently for this problem? *

Was there anything you weren't happy about from this treatment?

3rd Party

Department of Veteran Affairs (DVA)

Is your payment covered by DVA? *

YesNo

What is your card number? *

What card do you have? *

GoldWhite

Chronic Disease Management (CDM) Plan

Do you have a GP referral for this Chronic Disease Management Plan? *

YesNo

Name of the referring GP *

and the date of the referral

if you know their provider number

We need your Medicare number *

and Medicare reference number *

Third Party Payment e.g Workers' Compensation

Is treatment for this injury being paid by a third party? *

YesNo

Date of your accident *

Please write your claim number if you know it

Your employer's Insurers name *

Company phone number

Do you have a first medical certificate? *

YesNo

Have you completed a 2B Form? *

YesNo

I hereby authorise Esperance Physiotherapy to divulge to my employer and/or my employer’s insurer, information in relation to my injury. *

Medical Screening

Medical Screening Questions

Do you have high blood pressure? *

YesNo

Do you take regular prescribed medication? *

YesNo

Do you have faints or funny turns? *

YesNo

Do you have epilepsy? *

YesNo

Do you have regular prescribed medication? *

YesNo

Do you have panic attacks? *

YesNo

Do you have a tumor history? *

YesNo

Do you have asthma? *

YesNo

Do you have an allergy to metals? *

YesNo

Do you have diabetes? *

YesNo

Do you consume regular prescribed medication? *

YesNo

Do you have a bleeding disorder? *

YesNo

Do you have tuberculosis? *

YesNo

Do you have a pacemaker or other implant (e.g., breast)? *

YesNo

Do you have an autoimmune disease? *

YesNo

Please described *

Have you had a mastectomy? *

YesNo

Side?

LeftRightBilateral

Are you pregnant? *

YesNo

How many weeks are you? *

Have you used corticosteroid medications? *

YesNo

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 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 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, your health provider believes we can help, they will provide you with a personalised Action Plan. Booking future appointments lets you secure the most convenient treatment time, which also 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. 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. 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. To optimise your time with us, we use an AI program to record and transcribe your session. Once transcribed, we delete the recordings. Please let us know if you would prefer we don't use and AI program to transcribe your appointment with us.

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.

I have read and understood the statements above and I agree to the stated terms and conditions for treatment. I agree to this consent being valid until such time as I withdraw my consent. *

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