New Patient Information Form Name * First Name Last Name Date Of Birth * Email Address Phone Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country GP Name Occupation Injured Area Will you be claiming your treatment via any of the following? (Please Select all that apply) Medicare Refund (EPC) Private Health Fund WorkCover or CTP Please indicate by ticking any conditions below which may be applicable to you Pregnancy Diabetes Hearing or sight disability requiring aids Severe renal or cardiac disease The wearing of a cardiac pacemaker Arterial Disease Circulation disorders History of thrombosis Hemophilia Swelling/open woulds Osteoporosis/Osteomyelitis Acute infection/inflammation Skin conditions (e.g. eczema/dermatitis) Impaired Sensation (hot/cold/sharp/blunt) Hypersensitivity to head Benign/malignant Tumors Radiotherapy/chemotherapy Tuberculosis Metallic implants Current analgesic therapy Current Medications & Dose Do you have any allergies or are you sensitive to any dressings or drugs? * Yes No If yes, please specify Standard Warnings * HEAT TREATMENTS When receiving a heat treatment, all you should feel is a mild comfortable warmth. If you feel more than this or if the heat concentrates in on e spot you must call your PHYSIOTHERAPIST IMMEDIATELY, otherwise you may be in danger of being burned. ICE TREATMENT When receiving an ice treatment, you should feel the area receiving ice to go cold and numb. You may experience a short period of pain however you MUST report any SEVERE PAIN or LASTING PAIN to your PHYSIOTHERAPIST IMMEDIATELY as you are in danger of receiving an ice burn. DO NOT MOVE or TOUCH any equipment during treatment CLIENT UNDERSTANDING AGREEMENT I understand or indicate where applicable any contraindications, warnings and safety procedures. I will inform my physiotherapist of any changes in the information provided. That I undertake to pay the account in full on or before the due date. In default of such prompt payment I undertake to pay late payment fees of $5.00 per month on any amount outstanding and to indemnify us and pay all costs and expenses on a solicitor/client basis if legal action is necessary which we may incur in recovering from you any overdue amount. DO YOU UNDERSTAND AND AGREE WITH THE ABOVE INFORMATION? Yes No Thank you!
