Registration

TitleNote: Answer is optional.

First Name *

Preferred NameOptional

Last Name *

Preferred name alert

Date of Birth *

Mobile *

Email Address *

Gender *

What most accurately describes you?Note: Answer is optional.

Please share your pronouns belowNote: Answer is optional.

Home Address *

Suburb *

State *

Post Code *

Below address questions no longer used, however do not delete

Home Address *

Suburb *

State *

Post Code *

Emergency Contact

Name (Next of Kin + Parent Guardian) *

Relationship *

Phone *

Strong Kids/Strong HIIT

Provide details

Does your child have any chronic disability or chronic illness? *

YesNo

Provide details

Does your child take any medications? *

YesNo

Provide details

Has your child had surgery in the last 12 months? *

YesNo

Provide details

Has your child broken any bones in the last 12 months? *

YesNo

Provide details

Please inform us if there is anything else regarding your child's health that has not been mentioned

Medical

Doctor *

Medical Practice *

Medical Conditions

Osteoarthritis

Have you been diagnosed with Osteoarthritis? *

YesNo

Which joints? *

How long have you had this? *

Have you had surgery? *

YesNo

Which area? *

Medicare

Medicare

Medicare No *

Line *

Expiry Month *

Expiry Year *

Card Photo

Browse

Doctor Referral / Care Plan

Browse

(please also bring these with you to your appointment)

Private Health Cover

Private Health Cover

Provider *

Card No. *

Line *

Card Photo

Browse

Health Concession / Pension Card

Aged Pension Card

Card No

Upload photo of card

Browse

National Disability Insurance Scheme (NDIS)

National Disability Insurance Scheme (NDIS)

NDIS Number *

Management Type *

NDIS Plan

Browse

Workcover

WorkCover

Insurer *

Claim No. *

Date of Injury *

Claim Forms

Browse

Department of Veteran Affairs (DVA)

Department of Veteran Affairs (DVA)

Card Type *

White Card Clinical Text

Card Number *

Condition

Expiry Month *

Expiry Year *

Card Photo

Browse

Upload photo of referral

Browse

Health Screen - Conditions | Injuries

Pain Level

Orebro Score

Pain Risk

Exercise Pre-Screen

This screening tool is part of the Adult Pre-Exercising Screening System (APSS) that also includes guidelines on how to use the information collected and to address the aims of each stage. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Exercise & Sport Science Australia, Fitness Australia, Sports Medicine Australia or Exercise is Medicine for any loss, damage, or injury that may arise from any person actingon any statement or information contained in the system.

STAGE 1: COMPULSORY

AIM: To identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event due to exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual.

IF YOU ANSWERED "YES" to any of the 6 questions, please provide additional information below & seek guidance from your appropriate allied health professional or medical practitioner prior to undertaking exercise.

Further informationE.g. Currently pregnant

IF YOU ANSWERED "NO" to all of the 6 questions, please proceed to question 7 and calculate your typical weighted physical activity/exercise per week.

7. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities

Frequency
(number of sessions per week)

Light

Moderate

Vigorous/High

Duration
(total minutes per week)

Light

Moderate

Vigorous/High

Further ExplanationE.g. Attend F45 gym 3x week, run 1-2x per week max distance 5km, walk 3x per week approx 3km (9km total per week)

Weighted physical activity/exercise per week

TOTAL

Do you currently take any medications? *

YesNo

Please list *

I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.

Client signature

Clear

Date

Essa.org.au. 2021. Adult Pre-Screening Tool. [online] Available at: <https://www.essa.org.au/Public/ABOUT_ESSA/Adult_Pre-Screening_Tool.aspx> [Accessed 2 March 2021].

VO2 Profile

Height (cm) *

Weight (kg) *

Please select your preferred testing modality *

Treadmill (running)RowerN/A (Metabolic testing)

Health Information

SOZO Pre-Screen Form

To help us prepare for your consultation we would like to gather some information to setup a profile in our SOZO bioimpedance device.

The SOZO will calculate your current skeletal muscle mass. We can monitor for any changes (eg. fluid changes in your limbs) into the future.

Primary Diagnosis *Type of cancer / lymphoedema / other condition

HeightHeight in centimeters. If unsure, ask to be measured.

WeightWeight in kilograms. If unsure, ask to be weighed.

What is your dominant hand? *

LeftRight

Affected area details..

Have you had surgery? *

YesNo

Please provide details..Describe location(s) on body, date of surgery, etc.

Have you had surgery to remove lymph nodes? *

YesNo

Please provide details..Describe location(s) on body, date of surgery, etc.

Have you had chemotherapy treatment? *

YesNo

Please provide details..Date completed, or date commenced, or date due to commence.

Have you had radiation treatment? *

YesNo

Please provide details..Describe location(s) on body, date of treatment, side affects, etc.

Do you wear a compression garment? *

YesNo

Please provide details..Describe what you wear, how often?

Symptom Rating

Please rate your current experience of the treatment related symptoms listed below.

0 (None) - 10 (Worst Immaginable)

Additional comments..

Booking Info

Class Bookings

We offer recurring bookings so that you can have the same days and times available each week to secure your spot. These can be changed at any time to suit your lifestyle (subject to cancellation policy).

Please ask your clinician to book reoccuring bookings during your individual appointments.

Individual Appointments

All participants require an initial one-on-one assessment before starting classes. We want to see you thrive and achieve your health goals. We recommend 1:1 review sessions as needed to ensure your class program remains effective and relevant to your progress.

To keep your program safe and appropriately tailored, we ask that:

All participants require an initial one-on-one assessment before starting classes
If you’ve been away for 8 weeks or more, a brief review is required before returning to classes
If you’ve had time off due to injury/surgery, a review is required before returning to classes

These appointments are not included in your class memberships however may be subsidised by Medicare or Private Health cover.

Clinical Assessments

To properly assess your injury or condition, we may ask you to remove certain items of clothing so we can see how your body moves. You’re absolutely welcome to bring a friend, family member or support person to your appointment if you’d feel more comfortable.

Responsibility for Treatment

All treatment at PhysioHealth & Sports Injury Clinic is delivered by fully insured professionals. While we support and coordinate your care, any professional responsibility lies with your individual physiotherapist or exercise physiologist. Our team follows best-practice standards set by the Australian Physiotherapy Association and Exercise & Sports Science Australia.

Acknowledging Risk

By attending the clinic, you understand that using the gym and treatment spaces comes with some risk like the chance of slips, trips, or minor injuries. You accept these risks and agree not to hold PhysioHealth, our staff, or other clients responsible for any injury, damage or loss that might happen during your visit.

Medicare

You may recieve a Doctors referral for entitlement of a Medicare rebate for a set number of appointments.

We do not bulk bill Medicare. Full payment is required, and if you request we may send your claim to Medicare. Providing your bank details are stored with Medicare, you should recieve partial reimbursement.

Private Health

If you have Private Health ‘Extra’s cover’, you may be eligible to claim a portion of your fee’s. A gap payment for the balance will payable. Health fund rebates may be claimed as follows:

– Individual appointments: Pay on the day for on-the-spot health fund claims at reception
– Classes: Invoices can be provided on request for you to claim

Some health funds include a ‘health management program’ which can offer additional savings depending on your individual cover. This requires a form to fill out and submit with your attendance. Reach out to your health fund to check if you’re covered.

We find some health funds more generous to others. You may like to review your level of cover & compare at: https://privatehealth.gov.au

Third Party Payers

You may request that we send invoices to third party payers. This may include insurers such as Workers Compensation, CTP, NDIS, DVA, etc.

When you book an exercise physiology or physiotherapy session with our clinic, you agree to the following terms:

1. Funding Budget

It is your responsibility to ensure approval of your claim and funds have been approved by your third party payer prior to attending your individual appointment or classses.

2. Payment

If you don’t show up or cancel/reschedule within 24 hours, you will be charged the full cost of the session. This fee is your responsibility, even if your session is normally covered by a third-party. Most third-party payers do not cover missed or late-cancelled sessions, so you will need to pay the full amount yourself. You must pay for missed or late-cancelled sessions before booking any future appointments.

Direct Debit

Direct debit payments will be as per the Electronic Direct Debit Request Service Agreement (eDDRSA) available to view here.

We require at least 7 days notice to pause or cancel direct debits.

Cancellation Policy

At PhysioHealth we value your time and ours. When an appointment is cancelled at short notice or missed, we are generally unable to offer that time to another client in need.

The cancellation fee is nessesary to cover the cost of the clinician’s and administration time that would otherwise go unpaid. Fee reductions or exceptions may apply in cases of emergency or illness where evidence is provided.

Notice can be provided via phone, SMS, or email. We have outlined the notice periods and fee’s below:

1. Individual Appointments

Appointments cancelled or not attended will be invoiced as follows:

less than 24 hours notice 50% of the consultation fee
less than 4 hours notice 100% of the consultation fee

2. Classes

Classes cancelled or not attended will be invoiced as follows:

A mimimum of 4 hours notice is required to cancel a class, otherwise:
- Missed casual sessions will be forfeited
- A $10 fee applies for memberships per cancellation

Additionally, if you miss three (3) consecutive classes without providing appropriate notice, your reserved spot in the class will no longer be guaranteed. In this circumstance, the position may be released and made available to other participants.

We appreciate your understanding and support.

Refund Policy

Our refund policy is available at https://www.physiohealthcorrimal.com.au/terms-and-conditions/#refund-policy

Privacy Policy

Our privacy policy is available at https://www.physiohealthcorrimal.com.au/terms-and-conditions/#privacy-policy

CANCELLATION POLICY - A FEE OF $65.00 WILL BE CHARGED IF YOU FAIL TO ATTEND YOUR APPOINTMENT. 24 HOURS NOTICE IS REQUIRED FOR CANCELLATIONS. *

A patient may be expected to remove certain articles of clothing to allow for a detailed musculoskeletal assessment
A patient is entitled to bring a chaperone if they so wish to. *

I understand that I am participating in a general group exercise class that does not have an individualised program designed specific to me. These sessions are delivered in a group setting with general instructions, assuming a baseline level of health and fitness. *

I acknowledge that:
1. Small modifications can be made
2. If I have a significant injury or condition, I have been advised to undertake an individual assessment
3. I voluntarily participate and accept full responsibility for my health and wellbeing
*

PhysioHealth & sports injury clinic accepts no responsibility for the treatment received. Any professional liability is between the patient and the individual therapist [all PhysioHealth & sports injury clinic physiotherapists and Exercise Physiologists are insured through their respective insurance companies]. PhysioHealth & sports injury clinic adopts assurance protocols in accordance with the clinical guidelines as are specified by the Australian Physiotherapy Association and Exercise & Sports Science Australia. *

Acknowledgement and assumption of risk: You understand and acknowledge that; you will not hold us liable for any personal injury, damage to or loss of belongings which may arise from the clinic, our staff or clients. You take on full responsibility for potential risks associated with the use of gym equipment in a shared space such as the risk of slips, trips and falls. *

Read the full terms and conditions anytime on our website:

https://www.physiohealthcorrimal.com.au/terms-and-conditions/

I consent for PhysioHealth to capture pictures/videos of yourself at times throughout your treatment for posting on our website or Facebook page. PhysioHealth will always ask before taking a photo or a video.

Acknowledgment

You confirm that you have read and understood these terms and agree to follow them. You also agree to take responsibility for any fees due to missed or late-cancelled appointments.

Social Alert

Do you have any other comments or questions?

Signature *

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