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North City Physiotherapy General Information and Consent Form
Welcome to North City Physiotherapy, thank you for choosing us as your rehabilitation provider.
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?
What is the name your known by if this different from your first name?
What is your date of birth?
What is your home address
We need you street number, street name, suburb, city, and post code
What is your Ethnicity
Please check the box
NZ European / Pakeha
Cook Island Maori
Latin American / Hispanic
Other Pacific Islands
Decline to Answer
What is your home phone number?
What is your mobile number?
What is your work number?
What is your email address?
Refer to our terms and conditions in the final section for what we will use your email address for
Would you like to be subscribed to our client e-newsletter?
This full of interesting information about health, fitness and rehabilitation, plus happenings at our clinic. . You can opt out at anytime.
Who can we contact in case of an emergency?
Please state who this is, their relationship to you, and their contact phone number
Who is your GP, and/or which medical centre do you attend?
What is your occupation?
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
How Did you find out about North City Physiotherapy?
Recommended by someone else
I am a previous client
My GP / Specialist referred me
Yellow Pages Online
Location of the clinic
IF you were recommended by someone to see us, can we know who?
Are there any cultural/religious or any particular considerations you would like us to be aware off? If YES, please let us know...
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
Tawa Rugby Club
Tawa Football Club
Porirua Vikings Rugby League Club
Titahi Bay Marlens Rugby League Club
St George Rugby League Club
North Wellington Football Club
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