Initial Intake and Consent Please complete the from below to to help us provide the best care possible Personal InfomationName* First Middle Last Address* Street Address Address Line 2 City ZIP / Postal Code Is your Postal address different from above?* Yes No Postal Address Street Address Address Line 2 City ZIP / Postal Code Date of Birth* DD slash MM slash YYYY Doctors Name Specialist Name: Email Home PhonePhone WorkMobile PhoneHealth ConditionsPlease indicate which conditions apply to you Arthritis Asthma or Chest Conditions Cancer Diabetes Dizzyness Epilepsy Heart conditions Blood pressure Issues HIV/AIDS Hepatitis Blood Disorders Metal Pins / Joints Had Major Surgery Pregnant Pacemaker. Please list any conditions not listed above?Have you reacted to any previous treatments?*Are there any treatments that you do not want to have?*Terms and Conditions* I have read and understood the terms and conditions below. By submitting this form I agree to the terms and conditions of treatment.I consent to have treatment once it is adequately explained to me by the physiotherapist. I Understand that if acc decline my claim I am liable to pay for all physiotherapy fees. Payment for treatment is due on the same day, Unless prior arrangements have been made. If I fail to notify the clinic at least two hours in advance to cancel a scheduled appointment, I understand that there is a non-attendance fee to pay of $45.00 I understand that I am liable to pay ACC co-payment of $50.00 for the first consultation and $45.00 for any consultation thereafter. ACC Telehealth consultation co-payment fee $35.00 Telehealth Private Charges (No- ACC) $50.00 Private Charges (Non-ACC) $90.00
