Client Details - Client Registration Form

First Name *

Last Name *

Email Address *

Date of Birth: *

Mobile Number *

Work Number

Guardian name (if client is under 16)

Street Address *

City *

Postcode *

State *

Gender *

FemaleMaleNon-Binary

Additonal information

What body part/issue does your appointment relate to?

Occupation/Study *

Sport/Recreational Activities *

Have you seen another therapist for any previous or current injuries? *

YesNo

When you saw another therapist, what aspects were you most happy about *

When you saw another therapist, what aspects were you not happy about? *

What goals would you like to achieve from your treatment? *

Is there any urgency to fix your injury as soon as possible (eg. Wedding, overseas trip, sporting finals etc) *

Health Information

Name of Regular GP/Doctor: *

Phone Number *

Clinic Name *

Doctor Address *

Street address *

City *

State *

Postcode *

Do you have a referral from your doctor/GP *

YesNo

Please upload your referral here

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(NB: To upload your referral we suggest taking a photo of each page or use a scanning app on your phone. You are able to upload multiple images at the one time)

Do you have any reports of scans regarding your injury? (xray, MRI, ultrasound etc) *

YesNo

Please upload your scans, if possible

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Do you have a Chronic Disease Management Plan (or Enhanced Primary Care Plan) from your GP to claim your treatment under Medicare? *

Yes No

Is your Referral for:

PhysioExercise PhysiologyOtherNone

Upload Your Management Plan or Enhanced Primary Care Plan Here *

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(NB: To upload your plan and referral we suggest taking a photo of each page or use a scanning app on your phone. You are able to upload multiple images at the one time)

Do you have a DVA Card? *

YesNo

What type of DVA card do your hold?

White CardGold CardGold TPINone

Upload a screenshot of your accepted conditions as shown on your My Gov account *

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Upload your referral from your doctor here

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(NB: To upload your referral we suggest taking a photo of each page or use a scanning app on your phone. You are able to upload multiple images at the one time)

Is your appointment related to a Workers Compensation or Motor Vehicle accident insurance case? *

YesNo

Case Number: *

Insurance Company *

Case Manager *

Case manager direct phone number *

Case Manager Email Address *

Are you an NDIS client? *

YesNo

NDIS Number *

Are you privately managed or third-party managed? *

PrivateThird-PartyNone

Please upload your plan here

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(NB: To upload your plan we suggest taking a photo of each page or use a scanning app on your phone. You are able to upload multiple images at the one time)

Name of Third-Party Organisation *

Case Manager Name *

Case Manager Email *

Case Manager Phone Number *

Referral

Please let us know the name of the family or friend who referred you to us *

Please let us know the name of the Doctor who referred you? *

Terms & Conditions

Please agree to the following statements: *

1. I understand that I am responsible for the payment of my account and that payment is due at the time of my appointment.2. I have added my doctor/GP Details and my referral, if relevant.3. I have uploaded any reports that relate to my injury, if applicable.4. I understand that if I am claiming treatment from a third party payer (ie. workers compensation, motor vehicle accident insurers, DVA or from Medicare) and I haven't provided Sport & Spinal Physiotherapy with all of the information required, then I will be required to pay private rates at the time of the appointment5. I consent to Sport & Spinal Physiotherapy contacting relevant third parties in relation to my ongoing care and treatment such as my GP. I understand this is necessary to assist with my ongoing treatment.6. I understand that if I cancel my appointment within 24hours, a fee will apply.

Your Signature *

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