New Patient Form

(Please note the patient will be required to make full payment until a claim is fully approved and verified by our staff)

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)

Do you hold a concession card?

Concession Card Number

Concession Card Expiry

INSURANCE DETAILS

Insurance Company(required):

Insurance Company mailing address(required):

Case Manager(required):

Case Manager contact number (required):

Injury Date

Claim Number (required):

I understand that if my insurer does not cover the full costs there may be a gap payment that must be made on the day of services (Private Health may be used for this out of pocket expense; however it is at the discretion of the patient to know their policy in regards to claiming Gaps). I understand that should any claim for treatment be rejected by WorkCover, The Insurer, The Employer or Third Party that I am responsible for the total cost. I also authorise Physionorth to release clinical records to the insurer/Solicitor.

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

Please follow the link to the terms and conditions for insurance patients:www.physionorth.com.au/insurance-claims-ctp

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.