Are you visiting us because of a Workers Compensation claim or Motor Vehicle Accident? Yes No Workers Compensation claim or Motor Vehicle Accident – Patient Information Sheet Please fill in all details currently available to you. Please remember to bring your doctors referral and/or current medical certificate First Treatment Date Title MrMrsMissMs Given Names Surname Telephone Date of Birth Address Suburb Postcode Email Next of Kin Name Telephone Injury type Workers Compensation YesNo Motor Vehicle Accident YesNo Employment Details Occupation Employer Industry Contact Name Phone Number Address Postcode Date of Accident Claim details Have you lodged a Claim? YesNo Claim Number Insurance Company Status of Claim Case Officer Referring Doctor’s Name Address Phone Number Date of Referral Injury Details Brief description of problem: Existing Health problems Do you have an implanted cardiac pacemaker or any other device? YesNo Do you have any metal implants? YesNo Have you had any of the following health problems? Cancer/TumorHeart DiseaseEmphysemaDiabetesHepatitisAsthmaHay FeverAllergiesLung DiseaseTuberculosisHIVStrokeMeningitisRoss River FeverRheumatoid ArthritisPsoriasisSpinal FracturesOsteoporosisChronic FatigueSyndrome Other Please read and agree to the declaration on this form Authority to Release Information I hereby authorize any professional Staff member of Cannington Physiotherapy to divulge to my employer and/or my employer’s insurer, information in relation to my workers compensation or motor vehicle accident claim which he/she may have acquired with regard to myself. Acceptance of Responsibility for Payment of Account I acknowledge that in the event of any worker’s compensation or motor vehicle accident claim being denied, I am ultimately responsible for the payment of all outstanding invoices. If payment is not received, administration and debt collection charges, in addition to any outstanding monies owed may be incurred.. WARNINGS Please read the following information and indicate you understand these warnings by submitting the form below. Heat Treatment: When receiving a heat treatment, all you should feel is a mild comfortable warmth. If you feel any more than this, or if the heat concentrates in any particular spot, you must call your Physiotherapist immediately, otherwise you may be in danger of being burned. Electrical Stimulation: When receiving an electrical stimulation, any concentration of the current, or discomfort or pain must be reported immediately to your Physiotherapist. Otherwise, you may be in danger of sustaining an abnormal skin reaction. This may result in skin and tissue damage. Acupuncture Acupuncture treatment is a form of therapy in which fine needles are inserted into specific body points. Acupuncture is generally safe with serious side effects less than one per 10,000 treatments. Common side effects include drowsiness, minor bleeding (3%), pain during treatment (1%), increased pain after treatment (3%) and fainting. If acupuncture is provided to your trunk there is a risk of a pneumothorax and your physiotherapist will seek your consent before this treatment is provided. Skin reactions to massage oils, strapping tapes or acupuncture needles are a possibility. By clicking submit you indicate you understand and agree to all the above information. Private Patient Information Sheet First Treatment Date Title MrMrsMissMs Given Names Surname Telephone Date of Birth Address Suburb Postcode Email Occupation Current sports/hobbies Next of Kin Name Telephone Health Insurance Information Name of fund Membership # Pensioners Are you a Pensioner? YesNo If yes, what type of pension: Pension Number How did you find us? How did you hear about our Centre? Family/FriendEmployerStreet signDoctorYellow Pages BookHealth engineCannington Physio websiteHealth Fund WebsiteGoogleOther If person or other please specify: Medical Information Area of injury/Description of problem: Do you have an implanted cardiac pacemaker, defibrillator or any other implant? YesNo Do you have any metal implants?: YesNo Do you, or have you had any of the following health problems? (Please tick all that apply): Cancer/TumorHigh blood PressureDiabetesHepatitisOsteoporosisHIVMeningitisSpinal FractureHeart DiseaseEpilepsyRoss River FeverHay feverStrokePsoriasisTuberculosisAllergies (including metals)AsthmaBleeding DisorderLung Disease (ie. emphysema, bronchiectasis)Rheumatoid ArthritisChronic Fatigue SyndromeOther If other, please specify: Payment This is a private billing practice and we do require accounts are settled on the day of treatment. Cash, EFTPOS and credit cards are all accepted. Private health rebates can be processed prior to gap payment. Please be aware taping charges may apply and require payment on the day. INFORMED CONSENT Physiotherapy treatment is generally an effective and safe form of treatment, however like any treatment there are benefits and risks. The purpose of this form is to let you know what your rights are and how we address the issue of collaborative decision making and informed consent between you and your physiotherapist. Your physiotherapist 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 treatment for any reason including religious or personal grounds. Please read the following warnings and agree below; During the examination, assessment and treatment it may be necessary for your physiotherapist to make physical contact. Physical contact requires your express consent and you may withdraw at any time at which point all physical contact will be ceased immediately. Acupuncture treatment is a form of therapy in which fine needles are inserted into specific body points. Acupuncture is generally safe with serious side effects less than one per 10,000 treatments. Common side effects include drowsiness, minor bleeding (3%), pain during treatment (1%), increased pain after treatment (3%) and fainting. If acupuncture is provided to your trunk there is a risk of a pneumothorax and your physiotherapist will seek your consent before this treatment is provided. Skin reactions to massage oils, strapping tapes or acupuncture needles are a possibility. Electro-physical agents such as ultrasound, electrical stimulation, heat or cryotherapy are also used in this clinic. Heat therapy: All you should feel is mild warmth. If you feel more than this, or if the heat concentrates in any particular spot, you must call your Physiotherapist immediately, otherwise you may be in danger of being burned. Electrical stimulation: any concentration of the current, or discomfort or pain must be reported to your Physiotherapist otherwise, you may be in danger of sustaining an abnormal skin reaction. This may result in skin and tissue damage. Your personal health information and your health record may be collected, used and disclosed for various reasons. If you would like more information please ask your physiotherapist. If you have any concerns or wish to restrict access to your personal health information please discuss this with your physiotherapist or receptionist. The practice adheres to National Privacy Principles (www.privacy.gov.au) and has a written policy, which is available to all clients for inspection. Consent from a custodial parent is required to treat a minor. We recommend a family adult be present during treatment. Where a person is incapable of understanding the risks and benefits of treatment consent may be provided by another person legally authorised to provide such consent. By submitting this form I acknowledge I have read and understand the statements above relating to consent. I offer consent to receive treatment within this clinic. I agree to this consent remaining valid until such time as I withdraw my consent.
