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North City Physiotherapy General Information and Consent Form
Welcome to North City Physiotherapy in Cannons Creek, thank you for using us as your rehabilitation provider.

If you are registered patient at an Ora Toa Medical Centre, Porirua Union, or Pacific Health please fill in this form. If not please call us on 0800 627497 to get a different form.

Please take a few moments to complete our form below. All sections are required to be filled in

What is your First name and Surname?
Your answer
What is the name your known by IF different from your first name?
Your answer
Gender
What is your date of birth?
MM
/
DD
/
YYYY
What is your Home Address
We need you street number, street name, suburb, city, and post code
Your answer
What is your Ethnicity
Please check the box
What is your home phone number?
Your answer
What is your mobile number?
Your answer
What is your work number?
Your answer
What is your email address?
Refer to our terms and conditions in the final section for what we will use your email address for
Your answer
Would you like to be subscribed to our client e-newsletter?
This full of interesting information about health, fitness and rehabilitation. You can opt out at anytime
Required
Who can we contact in case of an emergency?
Please state who this is, their relationship to you, and their contact phone number
Your answer
Which medical centre do you attend?
Who is your doctor at one of the above medical centres? (if not sure let us know)
Your answer
What is your occupation?
Your answer
Are you self employed?
Please tell us how heavy your job is?
Please state your employer, employer address, and employer phone number
This is compulsory if you have had a work place injury
Your answer
How Did you find out about North City Physiotherapy?
Required
IF you were recommended by someone to see us, can we know who?
Your answer
IF you were recommended by one of sports club partners, please let us know who?
Discounts apply for injuries sustained playing or training for these clubs
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