Physio Effect Registration and Treatment Consent Form
Please complete the questions below
Date of birth: DD/MM/YYYY (please use exactly this format including '/')
Prefer not to say
How did you hear about us?
Personal Trainer/ Gym (please detail below)
From an existing Physio Effect Client (please tell us who)
Please let us know who referred you (if relevant)
Emergency Contact Name and Phone Number
Private Medical Insurance Details (if applicable):
please select your provider from the dropdown list below
Insurance Provider (please note there is a supplement to pay with some providers -
Other (please detail below)
If you answered "Other" above, please detail
Allowance for this injury/ issue (eg Initial appointment plus 4 returns):
Do you have any excess on your Policy? (please check your policy) If yes, please state amount
Do you have any of the following or any other condition that the practitioner should be made aware of?:
Other (please state):
Are you currently on any medication? : (please specify below if yes)
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