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ILEE PHYSIO: New Client Details Form
WELCOME! Please fill out your details and I'll get in touch with you as soon as possible! Ivan
Client Name *
Name of person receiving therapy
Your answer
Client Surname *
Your answer
Guardian Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Mobile Phone *
Your answer
Email *
Your answer
Address
Your answer
Emergency Contact Details *
Your answer
What Private Health Cover are you under?
Your answer
[NDIS only] How is your NDIS plan managed?
[NDIS only] What is your NDIS participant number?
Your answer
What is the reason for seeking our services today?
Your answer
Treatment Consent *
Physiotherapy treatment is an effective and safe form of treatment, however like any treatment there are benefits and risks. The physiotherapist will discuss your condition and options for treatment with you so that you are appropriately informed and can make decisions relating to treatment. You may choose to consent or refuse any form of treatment for any reason including religious or personal grounds. Typical physiotherapy carries a remote possibility of injury to structures such as but not limited to; nerves, bones, muscles, ligaments or arteries. Physiotherapy can occasionally cause local swelling, bruising or transient increases in pain or other symptoms. Allergic skin reactions to creams, tape, or needles are a possibility. You will be asked to expose the injured body part for assessment and treatment. Please inform your physiotherapist if you feel uncomfortable at any time, as alternative methods are available. Your physiotherapist may ask personal questions relating to your injury and how your injury impacts on your ‘activities of daily living’. The more information you provide, the more likely it is that the physiotherapist can provide effective treatment. If you feel uncomfortable with a particular question please let the physiotherapist know.
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Signed and Dated: *
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