Referring Doctor's practice name and address
Date of issue for Doctor Referral
Number of Physiotherpay treatments eligiable for partial reimbursement:
I understand that payment is required upfront and a partial reimbursement from Medicare can be processed in the clinic if you have registered your banking details with Medicare or at the local Medicare building.
Please tick the boxes if you (or you have in the past), suffer from any of the following:
High/low blood pressure
Other Lung conditions
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 (Please note these costs incurred cannot be reimbursed by Medicare.