Client Details Form

Personal Details

Title

Sex

Gender

Date *

First Name - Legal *

First Name - Preferred *

Last Name *

Date of Birth *

Email *

Mobile Phone (for SMS Reminders)

Tick if you would like to receive our monthly newsletter; Healthy News?

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?

Department of Veteran Affairs (DVA)

Is your payment covered by DVA? *

YesNo

What is your card number? *

What card do you have? *

GoldWhite

Enhanced Primary Care Plan (EPCP)

Do you have a GP referral for this Enhanced Primary Care 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' Comp or MVA

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 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.

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.

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. *

Signature

Draw signature|Type signatureClear