PHYSIOTHERAPY CLIENT’S REGISTRATION FORM PHYSIOTHERAPY CLIENT’S REGISTRATION FORMPersonal DetailsTitle *MrMrMrsMissMsMisterDrOtherTitle *Sex *MaleMaleFemaleIntersexFull Name *Date of Birth *Street Address *Suburb *ZIP / Postal Code *Occupation *Medicare NumberReference NumberContact DetailsPreferred contact methodMobileHomeWorkEmailMobile Number *0 / 10Phone Number(Work)0 / 10Phone Number(Home)0 / 10Email *Emergency DetailsEmergency Contact Name *Relationship *Emergency Contact Number *0 / 10Doctor/ GP DetailsDoctor’s NameDoctor's Phone Number0 / 10Clinic Name and Address:How did you hear about us?How did you hear about us? *GPDentistSpecialistFamily/FriendInternet/WebsiteOur WebsiteGoogle/OnlineInstagramFacebookOtherName Of Referrer *Appointment TypePlease select appointment type *PrivatePrivateCare PlanWork CoverTACNDISInjury netDVAPrivate Health InsuranceDo You Have Private Health Insurance? *Yes/noYesNoHealth Fund Name *Clients with TAC or Work Cover ClaimsIs This Injury A TAC Or Work Cover Claim? *Yes/noYesNoDate of Injury *Claim NumberCase Manager Name *Case Manager Contact *0 / 10Email invoices to: *Insurance Company *Veterans Affairs Clients OnlyVx Card NumberSelectWhite/GoldWhiteGoldReferral DateSpecial Offers & Updates CommunicationWe email our Client's with our Clinic newsletter and some health and wellness tips, special offers, Pilates updates, nourishing recipes for overall good health.Please tick if you DO NOT wish to receive.Declaration: The above personal information is correct to the best of my knowledge, and I understand that I will be personally responsible for my accounts if the claim is not accepted.Patient Signature: *Your name will be considered as signatureDate Signed: *Short Notice Cancellation PolicyIntroduction: Your physiotherapist will develop a plan with you that takes into consideration your lifestyle and goals of treatment. It is of benefit to you that you can schedule your appointments in advance to ensure you can adhere to the plan to the best of your ability, as well as reserving a place in the physiotherapist’s schedule. Although we will do our best to reschedule, cancel your appointment, missed appointments can delay your recovery. Our goal is to provide quality health care to all our patients in a timely manner. No-shows, late arrivals, and cancellations inconvenience not only our health providers, but our other patients as well. Please be aware of our policy regarding missed appointments Appointment Cancellation or Rescheduling: When you book your appointment, you are holding a space on our calendar that is no longer available to our other patients. To be respectful of your fellow patients, please call our clinic as soon as you know you will not be able to make your appointment. If cancellation or rescheduling is necessary, we require that you call our clinic at least 48 hours in advance. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time. How to Cancel or Reschedule Your Appointment: If you need to cancel your appointment, please call us on 03 9525 6077 between the business hours of 9:00 am – 5:00 pm (Mondays to Saturday). If necessary, you may leave a detailed voicemail message and we will return your call as soon as possible. You can also send us an email at reception@physiocure.com.au and we will reply to you as soon as possible. Short Notice Cancellations/ Rescheduling or No-Shows: A cancellation or rescheduling is considered late when the appointment is cancelled or rescheduled less than 48 hours before the appointed time. A no-show is when a patient misses an appointment without cancelling or rescheduling. In either case, we will charge the patient a $50 missed appointment fee. This fee is not covered by compensable bodies. For new patients’ first appointments, a no show or late cancellation will result in a full charge of the new patient fee. Clinical Pilates/ Pilates Short Notice Cancellations/ Rescheduling or No-Shows: Our Service Providers require at least 48 hours’ notice for cancellation or rescheduling of your appointment. You may be liable to be charged in full for the missed class. If you bought a package of 5, 10 sessions or 20 sessions, you would lose one session of your package, if you fail to provide a 48 hour notice of your missed appointment. NDIS Short Notice Cancellation/ Rescheduling or No-Shows: As of 1 July 2022, A cancellation is short notice when the participant either gives less than seven (7) clear days’ notice or does not attend the support within a reasonable time. If the cancellation is deemed Short Notice, the Service Provider may have the right to charge 100% of the agreed fee for the support. For example, if the participant arrived for their support 45 minutes late, you could consider it a short notice cancellation. Similarly, if they had a support scheduled for Thursday at 10am, and they gave notice the week before at 4pm on Thursday, it would be short notice. Work Cover/TAC/EPC (Care Plan)/DVA Clients Short Notice Cancellation/ Rescheduling or No-Shows: A cancellation or rescheduling is considered late when the appointment is cancelled or rescheduled less than 48 hours before the appointed time. A no-show is when a patient misses an appointment without cancelling or rescheduling. In either case, we will charge the patient a $50 missed appointment fee. This fee is not covered by compensable bodies but only out of pocket. Please note that Telehealth appointments are available to avoid Short Notice Cancellation or rescheduling fees. Short Notice Cancellation/ Rescheduling or No-Shows For Work Cover/TAC/DVA Clients Attending a Group Exercise: Our Service Provider require at least 48 hours’ notice for cancellation or rescheduling of your appointment. You may be liable to be charged in full for the missed class. Please note that Telehealth appointments are available to avoid Short Notice Cancellation or rescheduling fees. Why does a Short Notice Cancellation Policy exist? Protecting the health providers income is the main reason this cancellation policy exists. Last minute cancellations are, well, last minute – making it difficult to schedule jobs to fill the gaps they leave in the day. This means a lost opportunity for work, which all field service businesses want to avoid. Is there a limit to the number of times a Provider can charge Short Notice Cancellation? There is no hard limit on the number of short notice cancellations (or no shows) for which a provider can claim in respect of a participant. However, providers have a duty of care to their participants and if a participant has an unusual number of cancellations, then the provider should seek to understand why they are occurring. If you have any questions about this Cancellation Policy and would like further information, please contact us by any of the following means during business hours Monday to Friday. Physio Cure Level 1, 61 Brighton Road Elwood VIC 3184 Call: (03) 9525 6077 E-mail: reception@physiocure.com.auPatient Signature: *Your name will be considered as signatureDate Signed: *CONFIDENTIAL PATIENT CASE HISTORYAT Physio Cure & Physio First Clinics, we focus on your ability to be healthy. Therefore, answering the following questions will give us a profile of your health. Our Goals Are: • To address the issues that brought you to our practice. • To treat the cause of your condition (not just treat the symptoms) • To assist you in maintaining improved health and wellnessWhat is your major concern? *How long have you had this concern for and any known reason for it starting? *Have you had this or a similar concern in the past? *If you are experiencing pain, please tick the words that best describe your pain: *ConstantIntensity variesSharpTravelsComes and goesIntensity doesn’t varyShootingAchyDo you get: *Please SelectPins and NeedlesTinglingNumbnessWeaknessSince the problem started is it: *Please SelectAbout the sameGetting betterGetting WorsDoes the problem Interferes with: *Please SelectWorkSleepHobbiesLeisureWhat makes it worse? *What makes it better? *What activity do you do regularly? *What type of work do you do? *Have you seen any other health professionals for this problem? *GPSpecialistPhysioOsteopathChiropractorNaturopathChinese medicineMasse useOtherplease circle and provide name.provide name *List any medications you are taking: *Have you had or do you have Depression/Anxiety/any mental health issue such as Personality Disorder / ADHD/ Bipolar/ PTSD /Stress / Fear Avoidance / Autism / Asperger / Drug, alcohol or substance abuse/addiction? *Yes/NoYesNoif yes, please describe *Do you have any known allergy? *Yes/NoYesNoif yes, please describe *Do you have or have you ever been diagnosed with?High blood pressureHeart attackHeart problemsStrokes or blood clotsA pacemakerAn aneurysmDiabetesOsteoporosisRheumatoid arthritisCancerAnkylosing spondylitisPsoriatic arthritisReiter’s arthritisSpinal traumaSpinal fractureSpinal surgeryDislocationsLigament injuriesCartilage injuriesOsteoarthritisDizzinessVertigoEpilepsyRecent SurgeryPregnant Now (date)Skin Allergy to creams/tapingMemory issuesJudgment issuesMental Health issuesPsychological issuesI declare that the above information is correct to the best of my knowledge.Patient Signature: *Your name will be considered as signatureDate Signed: *Done Policies
