New Patient Form PATIENT DETAILS Name * First Name Last Name Date of Birth * MM DD YYYY Age * Phone Number * Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about Dora Pandeloglou Physiotherapy? Please select one Friend/Family Doctor/Specialist Google Social Media Other Referring Doctor Details (if applicable) Private Health Fund Medication/General Health PATIENT INFORMATION & CONSENT Informed Patient Consent * - As a patient you may be required to remove certain articles of clothing to allow for a detailed musculoskeletal assessment. - You may withdraw your consent at any time. - Risks will be explained prior to treatment at which time you may choose to discontinue with treatment. I hereby acknowledge that all the information I have provided to Dora Pandeloglou Physiotherapy is accurate to the best of my knowledge. If unsure of any information I will inform my practitioner. Privacy Policy Dora Pandeloglou Physiotherapy is committed to ensuring that all personal information that is disclosed in consultations and sessions will remain confidential and only be accessible by appropriate staff. All personal information is stored in a secure location protected from unauthorized access, modification or disclosure. Information * As a patient of Dora Pandeloglou Physiotherapy it is my responsibility to notify my practitioner if there are any changes to my medical condition including changes in medication. I give permission for Dora Pandeloglou Physiotherapy to contact my general practitioner or other allied health professionals to obtain any relevant information regarding my condition. Dora Pandeloglou Physiotherapy Rescheduling Policy Your reserved consultation time has been specifically allocated to you. To achieve maximum improvement in the shortest possible timeframe, it is vital that you maintain your advised schedule of care. If you are unable to make your appointment time, a minimum of 24 hours notice is expected for Physiotherapy appointments. This enables us to make the appointment available to someone who really needs to come in for care. A courtesy phone call/SMS/email to reschedule your appointment is appreciated, otherwise a standard rescheduling fee of the cost of the service you requested will be incurred. Consent to Treatment * I have read and understand the above information and give my consent to treatment. I agree to this consent remaining valid until such time as I withdraw my consent. I also agree and give consent for my case to be discussed with Dora Pandeloglou Physiotherapy practitioners, treating doctor and 3rd party bodies if appropriate. Thanks for completing the New Patient Form!
