New Patient Form

Title (required)

Your First Name (required)

Your Last Name (required)

Date of birth (required)

Your Email (required)

Street Address (required)

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 Massage Therapist before ?

If yes, were you happy with the massage ?:

Why/Why Not ?:

What level of pressure do you prefer ?:

What Type of Massage do you prefer ?:

Swedish
Remedial
Sports
Unsure

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 (please note only one can be used if you have more than one concession and must be sighted at time of booking)?

Concession Card Number

Concession Card Expiry

You can receive a concession if you are an employee for the below categories (employee I.D must be sighted to verify at time of booking)

Are you a Defence Force Personal?

Are you an Emergency Services Personal (Paramedic, Police Officer, Fire Figther or SES)?

Are you a Townsville City Council Employee?

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.

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.