Mr
Mrs.
Miss
Ms

Name

Date of Birth

Address

Post Code

Phone (H)

(W)

(Mob)

E-mail*

Occupation

How did you hear about us? (please let us know so that we can thank them)

Doctor
Family
Friend

Advertising :

Local directories
Yellow Pages
Letter Box Drop
Bowling Club
School Newsletter
Sign
Brochure
Other

Private health insurance with Physio/Exercise Physiologist cover :

Yes
No

Please tick which of the following describes what you would like out of your initial Physiotherapy session?

Hands on treatment to relieve pain
Education and opinion on managing your injury
Development or review of exercise program

1.

2.

Area of Injury

Thank you for visiting Pottsville and Cabarita Physiotherapy. Your goals and aspirations are very important to us. To help us meet those goals, can you please tick any of the 3 models of care below which would be of interest to you.

RELEIVE YOUR PAIN
RESTORE YOUR CORE AND MOVEMENT TO
HELP PREVENT RECURRENCE
PERFORM AT YOUR BEST

Medicare

Your doctor has referred you to Physiotherapy under the Enhance Primary Care Plan (EPC). At Pottsville Physiotherapy we bulk bill all Pensioners, Health Care Card Holders and Students so there is no out of pocket expense. All that we require is that you present your Medicare card for your initial consultation. Medicare dictates that the maximum amount of visits any person is eligible for in a calendar year (Jan-Dec) is 5 for all ALLIED HEALTH CONSULTATIONS .

This means that if you have seen the podiatrist twice, you will only be eligible for 3 Physio visits or vice versa in that year no matter when your referral is dated or what number the doctor has put on your form.

It is your responsibility to ensure you do not claim more that 5 visits per calendar year. If you do, Medicare will notify us and it is expected that you will pay for the Physiotherapy consultation retrospectively.

I understand that I am only eligible to claim for a maximum 5 ALLIED HEALTH VISITS per calendar year. If I claim more than 5, I understand that Medicare will notify the provider and that I WILL PAY for the visits greater than 5 myself.

Date

Worker’s compensations claims

You will need to provide the following information to claim your treatment.

Employer’s Insurance company

Insurance claim number

Case Manager

Phone

Employer

Employer's Address

Employer's Contact Person

Contact Person Phone Number

Date of Injury

Area of Injury

You are obligated under work cover to attend Physiotherapy/Exercise Physiology treatments at your therapist’s discretion to allow for optimal recovery from your injury. The purpose of this is so that you can be pain free and back to work as soon as possible. It is not a problem if you need to change your appointment but we do require that you give us at least 4 hours notice or YOU WILL BE CHARGED a $40.00 cancellation fee.

IN THE EVENT OF DISPUTED LIABILITY REGARDING THIS INJURY, I AGREE TO BE PERSONALLY RESPONSIBLE FOR CONSULTATION FEES AND EQUIPMENT.

Date

Third Party Claims

You will need to provide the following information to claim your treatment.

Insurance Company

Insurance claim number

Case Manager

Phone

Fax

Date of Injury

Area of Injury

You are obligated under third party to attend Physiotherapy/Exercise Physiology treatments at your therapist’s discretion to allow for optimal recovery from your injury. The purpose of this is so that you can be pain free and back to work as soon as possible. It is not a problem if you need to change your appointment but we do require that you give us at least 4 hours notice or YOU WILL BE CHARGED a $40.00 cancellation fee.

IN THE EVENT OF DISPUTED LIABILITY REGARDING THIS INJURY, I AGREE TO BE PERSONALLY RESPONSIBLE FOR CONSULTATION FEES AND EQUIPMENT.

Date

Contraindications to treatment

If you suffer from any of the following some of the treatments performed by the Physiotherapist may not be appropriate for you.

Do you have, or suffer with any of the following?

Pacemaker or Electrical Implants
Epilepsy
Fainting or Fitting
Diabetes
Blood Clots, Thrombosis or Stroke
Bleeding Disorders
Metal Allergy
Other

Do you take anti-coagulant medication?

Warfarin
Aspirin
Other

Do you have any particular risk of infection?

Chemotherapy
Immunosuppressant medication
Other

Do you have any immune disorders ?

Cancer
Hepatitis B
HIV/AIDS
Other

Do you have any Artificial Implants?

Joint replacement
Metal plates/pins
Breast implants
Other

Are you Pregnant ?

Yes
No

What medication do you take ?

As with all forms of treatment there are RISKS associated with Physiotherapy treatment. Your Physiotherapist will discuss any foreseeable risks with you prior to administering treatment.

NON ATTENDANCE: Due to the fact that we provide one-on-one hands –on consultations and set aside time for you, please give at least 4 hours notice if you are unable to keep your appointment.

Reminder calls are available upon request.

Missed appointments will attract a non-attendance fee of $40. Thank you for your courtesy in this matter.

Consent to treatment

It is required that you confirm your intention to receive advice and treatment during your Physiotherapy consultation and that you allow professional communication among the health care team when appropriate for the management of your complaint.

I have read, understood and am in agreement with the conditions outlined above. I have indicated any contraindications to treatment. I give my consent to treatment.
I also understand that you have a non attendance fee of $40 if I do not give you 4 hours notice when cancelling an appointment.

Date

Phone

This field is for validation purposes and should be left unchanged.

Patient information form

Medicare

Worker’s compensations claims

Third Party Claims

Contraindications to treatment

Consent to treatment

Locations

Hours

Map