PHYSIOTHERAPY CLIENT’S REGISTRATION FORM
Personal Details
Contact Details
Emergency Contact:
Doctor/ GP Details:
How did you hear about us?
Appointment Type
Private Health Insurance
Clients with TAC or Work Cover Claims
Veterans Affairs Clients Only
Special Offers & Updates Communication
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.
Short Notice Cancellation Policy
Introduction:
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.
Clinical Pilates/ Pilates Short Notice Cancellations/ Rescheduling or No-Shows:
NDIS Short Notice Cancellation/ Rescheduling or No-Shows:
Work Cover/TAC/EPC (Care Plan)/DVA Clients Short Notice Cancellation/ Rescheduling or No-Shows:
Short Notice Cancellation/ Rescheduling or No-Shows For Work Cover/TAC/DVA Clients Attending a Group Exercise:
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.au
CONFIDENTIAL PATIENT CASE HISTORY
AT 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 wellness
I declare that the above information is correct to the best of my knowledge.
Treatment Informed Consent Form
Physiotherapy treatment is generally an effective and safe form of treatment, however, like any treatment there are benefits and risks, and responses to treatments are unique per individual. The purpose of this form is to let you know what your rights are and how we address the issue of a collaborative decision making and informed consent between physiotherapists and patients.
Please Read and Sign The Following:
Our physiotherapist in this practice will discuss your condition and options for treatment with you so that you are appropriately informed and can make decisions relating to treatment. You may choose to consent or refuse any form of treatment for any reason including religious or personal grounds. Once you have given consent, you may withdraw that consent at any time. This practice is committed to complying with the Privacy Act 1998 and the Australian Privacy Principles 2014. Please refer to our Privacy Policy, attached to the clipboard, for further details.
Mobile Phones:
Out of respect to others please turn your phones off or to silent.
Individual Response:
Every individual has a unique rate of healing and response dependent on many factors, such as general health, co-morbidities, periods of adequate rest, age, genetics, etc. If you are concerned about your response to treatment, you are encouraged to discuss this with your physiotherapist.
Referrals:
Word of mouth referrals are a great compliment and ensure the success of this clinic. We greatly appreciate your referrals of family and friends. Furthermore, if you have suggestions, comments, or complaints, we encourage you to inform our staff or submit in writing.
Questions Of A Personal Nature:
Your physiotherapist may ask personal questions relating to your injury and how your injury impacts on your ‘activities of daily living’. The more information you provide, the more likely it is that the physiotherapist can provide effective treatment. It is your choice as to what information you choose to provide. If you feel uncomfortable with any question, please let the physiotherapist know and they will cease. Our staff adheres to the privacy and confidentiality act, but also understands the trusting relationship that is required for such disclosure of your personal information, and endeavour to treat this material with the upmost respect.
Accounts/Fees:
Private patients are required to cover their fees at the time of service. We have installed HICAPS facilities for automatic and instant health fund claims to make this easier for you. TAC and DVA clients’ accounts will be sent directly to the appropriate body as required. Clients with Work Cover Claims are required to pay in full and we will provide them with an invoice and receipt to be reimbursed by their insurer or employer. Clients with Care Plans (EPC) are required to pay in full and Medicare rebate can be processed at our clinic if you hold a debit card.
Physical Contact:
During the examination, assessment, and treatment it may be necessary for your physiotherapist to make a physical contact. Your physiotherapist will ask your permission before making physical contact with you in any way. Wherever possible, contact will be made using a towel or other forms of screening. (e.g., a gown). Physical contact requires your express consent. You may withdraw consent at any time at which point, all physical contact will cease immediately. Please inform your physiotherapist if you feel uncomfortable at any time.
Children And Minors:
For the treatment of a minor this form must be signed by a custodian. Presence of a parent or caregiver is requested for anyone under the age of 16 years receiving treatment.
Substituted Consent:
Where a person is incapable of understanding the risks and benefits of treatment, consent may be provided by another person legally authorized to provide such consent. Evidence of legal authorization is required in such circumstances.
You need to let us know:
The risk related to some treatments can increase if the physiotherapist is not aware of certain facts
Risk Related To Treatment:
Typical physiotherapy carries a remote possibility of injury to structures such as but not limited to, nerves, bones, muscles, ligaments, discs, or arteries. Manual therapy (including dry needling, exercise therapy and postural retraining) can occasionally cause local swelling, bruising, bleeding, infection or transient increase in pain, or other symptoms. Electro-physical agents such as ultrasound or interferential therapy or TENS machine or shockwave therapy or heat or cryotherapy (ice) have been linked to minor burns and abnormal skin reactions. Allergic skin reactions to creams, oils, tape, or needles are a possibility. Skin deformation that occurs when sports taping is applied may also irritate the skin in some individuals. If any discomfort, redness or itching is experienced remove the tape immediately.
Tape Removal:
Sports taping should be removed carefully by soaking the tape in nail polish remover, baby oil or a commercial tape removal product. The skin should be supported by one hand and gentle counter traction provided against the direction the tape is being pulled. The skin should be thoroughly washed and moisturised following removal. Stretchy "K" style tapes or dynamic tapes are best removed by soaking or showering or soaking in warm water until tape and all residues have been removed.
Dry Needling:
is a broad term referring to the use fine needles to stimulate the tissue and nervous system to address musculoskeletal conditions. Dry Needling, was pioneered at the clinic and has been taught around the world since the early 1990's. Most of the insertions involve no sensation at all. Occasionally a sharp insertion sensation occurs due to skin stretch at the insertion site. This is like what occurs when pulling a hair and occurs in 1 out of every 30 insertions. We recommend this modality in most treatments to address tissue and nervous system sensitivity (often perceived as tightness), inflammation, neurological muscle inhibition (often perceived as weakness) and to stimulate remodelling of maladapted connective tissue structure.
Potential Risks And Side Effects Of Dry Needling:
Pneumothorax (Puncture/Collapsed Lung):
This is extremely rare with a possibility less than 1 in 70,000 - 1.27 million treatments and most of these instances are preventable with correct risk factor screening and technique application. All of the practitioners at Physio Cure have extensive training in the dry needling techniques they use and the identification of any risk factors and prevention measures to further minimise this occurring. If you experience increasing shortness of breath, that may or may not be accompanied by pain, following dry needling over the posterior shoulders or upper trunk, please contact Physio Cure by text and email or attend to the nearest hospital emergency department for an assessment.
Infections:
are possibility but are extremely rare when single use disposable needles are used. Physio Cure uses only single use, disposable needles. Some people have been reported to experience minor skin irritation in response to the metals used in the needles. These rare adverse effects combined occur in less than 1 in 10,000 treatments.
Fatigue and Drowsiness:
Following treatment and before driving or cycling, ensure you are not feeling drowsy or fatigued. If you do experience this, consult your practitioner for advice and possibly assistance with alternative travel arrangements. Have a snack or drink and rest until you feel that you have recovered. If you have previously experienced extreme fatigue or drowsiness after acupuncture or dry needling, please inform your practitioner prior to treatment and arrange for someone else to drive you to and from the appointment.
Discomfort following treatment:
It is very rare for people to experience any discomfort as a result of the dry needling techniques used at Physio Cure. Some new soreness may be experienced as a result of changes in the mechanical and neurological loading of nerve and tissue structures as a result of altered ranges of motion following treatment. This will usually resolve within hours and a few days.
Apparent minor bruising:
Approximately one in thirty needle sites will expel 1-2 drops of blood following needle removal. A further one in thirty will result in a small bump (subdermal haematoma) under the skin that may then resolve leaving what appears to be a bruise. These are not associated with impact or tissue damage and will be absorbed within 1-3 days in a healthy individual.
Grade 5 Manipulation Consent Form:
Grade 5 manipulations are a treatment technique in which a fast, small amplitude, passive manual mobilization of a joint (commonly known as cracking or adjusting) is used to gap one or more synovial joints with the aim of improving joint mobility and reducing pain.
Manual Therapy Treatment (Manipulation, Mobilization Or Soft Tissue Techniques):
Is recommended by National Institute for Health and Care Excellence (NICE) in the management of back pain as part of a treatment package.
Indications For A Grade 5 Manipulation Include:
Stiffness/ Reduced Range of Movement / Pain / Muscle spasm.
In Very Rare Cases The Following Complications May Occur As A Result Of Having A Grade 5 Joint Manipulation:
The likelihood of developing any serious side effect following manipulation is extremely rare; the incidence of having a stroke after cervical manipulation is 1 in 20,000 to 1 in 1 million, the incidence of cauda equina after lumbar manipulation is less than 1 in 1 million manipulations (Assendelft et al. 1996)
There are some occasions where a manipulation should not be performed:
The circumstances where extra caution needs to be taken, although a manipulation can still be performed:
(Previous adverse reaction / Disc prolapse / Pregnant / Under 16’s / Spondylolisthesis / Vertigo / Hypermobility).
Patient Consent:
The Physiotherapist has explained the treatment process of spinal manipulation to me including the risks, benefits, material risks & alternatives. I have answered all of the above questions to the best of my knowledge. I give my consent to the use of the spinal manipulation for my treatment.
Cervical Arterial Dysfunction (CAD) and Vertebral Basilar Artery (VBI) Signs and Symptoms:
Major Risk Factors for CAD:
Labyrinthitis Protocols for CAD:
After subjective identification of any potential CAD symptoms, further questioning must reveal the type, duration, frequency, degree and status of symptoms.
- Check for any aggravation of symptoms with head movements
- Check the nature and type of any associated symptoms, especially headaches
- Check for any previous medical history of migraines, epilepsy, cardiovascular history, head injuries, stroke, and vestibular problems.
Specific CAD tests have been found to hold little predictive value in the incidence of onset with manipulation. Therefore, judgement on when to use manual techniques should be based on information gained during a thorough subjective examination, with considered weighing up the presence of risk factors (Kerry et al 2008).
