New Patient Form

Title (required)
Your First Name (required)
Your Last Name (required)

Date of birth (required)

Street Address (require:d)
Suburb (required)
Post Code (required)
Postal Address (If different from above)
Phone Home
Phone Mobile (required)
Current Doctor
Private Health Fund
Occupation (required)

Have you been assessed by a Physiotherapist before?

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

What aspects were you most happy with?

Next of Kin (required)

Next of Kin contact number (required)

Do you hold a concession card?

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?

Are you a Women's Health Patient?

If you said yes to being a WH paitient, please tick the boxes below if you have any of these symptoms:

Urinary Incontinence
Bowel Incontinence
Pelvic Organ Prolapse
Pelvic pain including during sexual intercourse
Ante-Natal
Post-Natal

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 see other health professional's and/or personal trainer's 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?

I understand that 24 hours notice is required if I need to reschedule my FREE Physiotherapy Assessment, if not this offer will become invalid - if I no show to this appointment the offer will also be invalid - this offer is valid once only - non-transferable to any other service or offer

I agree with the CANCELLATION/NO SHOW 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 up to $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.