Consent to assessment and treatment

I hereby agree to consent to treatment by an appropriately qualified Physiotherapist for the purpose for providing comprehensive physiotherapy services as may be necessary in support of my illness, injury or condition. This will involve my physiotherapist asking me personal questions relating to my injury/condition and how it impacts on my activities of daily living. It is my choice as to what information I provide, and if I feel uncomfortable with a question, I will tell my physiotherapist. During the physical examination, I understand my physiotherapist will make physical contact with me. For Woman’s Health appointments, this may include an internal vaginal examination. I understand my physiotherapist will discuss the assessment, diagnosis and treatment options with me, including the benefits, side effects and complications of each treatment option. I can choose to consent or refuse any form of assessment or treatment for any reason and at any time.

Dry needling is a form of acupuncture, involving needles being inserted into the skin. The benefits and complications of dry needling have been explained to me and understand I can withdraw this consent at any time. I understand I have the right to decline part or all treatment being offered.I understand my right to a second opinion.

Agreement to pay

I understand that I am liable to pay for:

·         All private/women’s health treatment and copayment charges for ACC treatments

·         If I fail to attend my appointment or cancel without 24 hour’s notice, I will be charged a $50 fee

·         If I fail to pay for my appointment at the time of treatment, I may be charged an account administration fee of $10

·         Credit card surcharge of 2% of total payable

·         Any treatment that is declined by ACC or another funder

·         The costs of materials such as orthotics, products, strapping tape, needles.

I understand that if this service requires to engage a Debt Recovery Service to recover my debt, I will be liable for any recovery fees

Consent to release information to a 3rd party

I consent to the disclosure of my records to any person/organisation necessary for the effective management of my condition.

I consent to a discharge/update report being sent to my GP/medical centre/specialist.

Privacy Policy

Wont give you information to anyone else