Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Will you be claiming your treatment via any of the following?

Select all that apply

Medicare Refund (EPC)

Private Health Fund

Workcover/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

Cardiac pacemaker

Arterial disease

Circulation disorders

History of thrombosis

Haemophillia

Swelling/open wounds

Osteoporosis/Osteomyelytis

Acute infection/Inflammation

Skin conditions (e.g. Eczema/Dermatitis)

Impaired Sensation (hot/cold/sharp/blunt)

Hypersensitivity to heat

Benign/malignant Tumors

Radiculopathy/chemotherapy

Tuberculosis

Metallic implants

Current analgesic therapy

Do you have any allergies or are you sensitive to any dressings/drugs? *

Yes

No

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