New Patient Form

(Please note that if you hold a DVA White card we will require a copy of the specific letter DVA sent you in regards to your approved areas of treatment this must be presented to our staff and verified before treatment commences)

Date of birth (required)

Title (required)
Your First Name (required)
Your Last Name (required)
Your Email (required)
Street Address (require:d)
Suburb (required)
Post Code (required)
Postal Address (If different from above)
Phone Home
Phone Mobile (required)
Referring Doctor
Area of treatment (required)
Private Health Fund
Occupation (required)

Have you seen another Physiotherapist before?

If yes, is there anything you weren't happy about?

What aspects were you most happy with?

HOW DID YOU FIND PHYSIONORTH (required)

If Family/Friend or Other was selected please specify who referred you (as they will be rewarded for referring to us)!

Next of Kin (required)

Next of Kin contact number (required)

DVA Details
DVA Number

Referring Doctor

Referring Doctor's practice name and address

Date of issue of Doctor Referral

I understand that should any claim for treatment be rejected by the Department of Veterans affairs that I am responsible for the total cost.

I have read and understood the terms and conditions on the Physionorth website for DVA patients.

See link to the DVA terms and conditions of treatment go to www.physionorth.com.au/dva-claims

Please tick the boxes if you (or you have in the past), suffer from any of the following:

Cancer
Heart Condition
Epilepsy
High/low blood pressure
Circulation/Vascular problem
Other Lung conditions
Diabetes
Thyroid condition
Neurological condition
Arthritis
Osteoporosis
Depression
Stroke
Skin conditions (including allergies to tapes)
Do you have a pacemaker

If you ticked any of the above, please provide further details below:

Are you currently taking any medications (Please list or write none) (required)

Please explain the area/s that are most painful/causing the most difficulty: (required)

Please list any recent injuries

If you have been referred by another health professional and/or personal trainer do you hereby authorise Physionorth to discharge relevant clinical information to them?

Do you also authorise Physionorth employee's to obtain information and documentation regarding medical treatment you have received from other health practice's, as well as correspondence from clinic's that is received from other health practitioners that is relevant to your treatment

Do you authorise Physionorth employee’s to disclose your contact information to specialists we may refer you to so they can make contact with you for appointment bookings?

CANCELLATION POLICY AGREEMENT: If for some reason you need to move or cancel future appointments we will require 24 hours' notice otherwise a cancellation fee of $65 may be charged (these costs cannot be billed to any third party insurance/WC/DVA, it is a liability the patient incurs!).

I understand my email address will be added to the Physionorth database for access to the Exercise App and Online bookings - see privacy policy

Privacy Policy: All client details are stored confidentially with your clinical notes and not disclosed to anybody outside Physionorth. Email addresses added to the Physionorth database for access to the Exercise App and Online Bookings may also occasionally receive material at the mailing or email address listed in this form from Physionorth regarding promotions, discounts, updates, products & services