Client Details Form

Please complete the following form prior to your appointment if you are a new client or an existing client attending for a new problem.

BOOKING DETAILS

Please select your booking location *

Have you attended a Core Physiotherapy & Pilates Studio practice previously? *

YesNo

PERSONAL DETAILS

First Name *

Last Name *

Preferred NameIf different to First Name

Gender *

MaleFemaleOther

Please enter your Gender Identity

Date of Birth *

Mobile Phone *

Email *

Street Address *

Suburb *

State *

Postcode *

Occupation *

Employer

Emergency Contact Person Name and Phone Number *

General Practitioner Name & Address *

BILLING DETAILS

Do You Have Private Health Physio Extras Cover? *

YesNo

Health Fund Name *

Membership No.

Card Rank/ID Number

Do you have a Medicare Allied Health Referral form from your Doctor for todays visit? *

YesNo

Medicare Card Number *

Individual Reference Number *

Card Expiry Date (MM/YYYY) *

Please attach a copy of your GP Referral here

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NOTE: A valid GP Chronic Condition Management Plan is required to be eligible. If we do not have your GP referral prior to your appointment we will be unable to submit your claim to Medicare on your behalf and full payment at the time of your appointment is required.

Check the box to confirm you understand and accept the below terms & conditions of accessing Medicare funded services.

Terms & Conditions

If you have been referred by your GP on a GP Chronic Condition Management (previously GP Management Plan/Team Care Arrangements), please read below for information on conditions relating to the payment of your account. It is important that you understand these conditions prior to commencing your treatment.

You must provide all information as requested in this section of the form and attach a copy of the Medicare Allied Health Referral itself if you wish to claim a Medicare rebate for our services.
Billing - Core Physiotherapy & Pilates Studio is a mixed billing practice. Depending on the Physio seen we may charge you our full private fees upfront (payable at the time of your appointment) or elect to Bulk Bill your appointment. If you are unsure of the billing arrangements for the Physio you are seeing please contact our reception team.
Core Physiotherapy & Pilates Studio agrees to submit claims to Medicare on your behalf provided we have been provided information required to verify your eligibility in accordance with this form. In the case of services that are to be paid upfront we may submit the claim to Medicare on payment of your account. For Bulk Billed services we will submit the claim to Medicare directly and no payment will be required unless section 4 or 5 below apply.
You agree that you are ultimately responsible and liable for all fees and charges in respect of physiotherapy services provided by Core Physiotherapy from time to time. Accordingly, if for any reason medicare rejects or refuses to accept financial liability or ceases to make payment in relation to the services provided to the Client by Core Physiotherapy & Pilates Studio, you will be required to pay all outstanding amounts within fourteen (14) days of receiving notification from Core Physiotherapy & Pilates Studio.
If there is any shortfall between the amount which has been invoiced for services rendered to the Client and the sum which has been paid by any Approved Insurer or Statutory Authority, then the Client agrees to pay the amount of the shortfall within fourteen (14) days of receiving written notification from Core Physiotherapy.
Medicare referrals can only be used for individual services and not in conjuction with any other funding eg Private Health or promotional offers.

Check the box to confirm you understand and accept the below terms & conditions for accessing Medicare subsidised services.

Terms & Conditions

Core Physiotherapy & Pilates Studio Plympton is a private billing practice.
Bulk Billing is not available at this practice location.
All Medicare subsidised appointments must be paid in full at the time of your appointment.
Upon full payment of your invoice Core Physiotherapy & Pilates Studio will submit your claim via Medicare Online
Medicare usually reimburse any benefits payable to you within 1-2 days into your nominated bank account. Please note due to Medicare privacy rules Core Physiotherapy & Pilates Studio can confirm we have submitted a claim to Medicare on your behalf but are unable to investigate on your behalf if your claim is denied or payment withheld by Medicare.
Medicare referrals can only be used for individual services and not in conjuction with any other funding eg Private Health or promotional offers.

Do you have a DVA card? *

YesNo

DVA No.

Please upload a picture of your card for verification

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Treatment Cycle Requirements: Please note DVA have introduced a Treatment Cycle model which requires you to visit your referring GP at the end of each 12 Physio/Exercise sessions or one year, whichever ends first. If you believe this may adversely impact on your ability to access our services please discuss with your GP about completing the DVA At RIsk Client Framework form available here .

I understand that other musculoskeletal services (exercise physiology, chiropractic, osteopathy and physiotherapy) cannot be claimed on the same day as a Physiotherapy service. If you require other such musckuloskeletal services in addition to ours please ensure they are booked on different days or you will be liable to pay the full amount.

*

Are you attending for a Work or Motor Accident Injury? *

Yes (Work Injury)Yes (Motor Injury)Yes (Early Intervention Program)No

Do you have an active approved work injury claim? *

YesNo - Paying Privately For NowSubmitted - Awaiting Approval

Do you have an active approved motor accident claim? *

YesNo - Paying Privately For NowSubmitted - Awaiting Approval

I understand that I will be required to pay in full at the RTWSA gazetted rates until Core Physiotherapy & Pilates Studio have received written/email approval of my eligibility to claim. *

Employer *

Date of Accident *

Work Injury Claims Agent *

Motor Accident Claim Agent *

Claim Number *

Case Manager *

Case Manager Contact Number *

I understand and accept that should my claim status change or the Claims Agent/RTWSA decline to pay any invoices for services provided to me by Core Physiotherapy & PIlates Studio I will be required to pay the full outstanding balance within 14 days of notification of the outstanding account. *

I understand and accept that should my claim status change or the Claims Agent/MAC decline to pay any invoices for services provided to me by Core Physiotherapy & PIlates Studio I will be required to pay the full outstanding balance within 14 days of notification of the outstanding account. *

Early Intervention Provider *

Employer_ *

Is this referral for a work or other injury *

Work Related InjuryNon-Work Related Injury

A referral from the Early Intervention Provider is generally required prior to booking your appointment. Please confirm we have received a referral prior to attendance or you may be liable to pay for the appointment fee personally. *

Are you attending for appointments under an NDIS Funded Plan? *

YesNo

How is your NDIS Plan Managed? *

Self ManagedPlan ManagedNDIA ManagedUnsure

NDIS Participant Number

NDIS Plan Goals (as stated in your NDIS Plan)

Services Required

In Clinic PhysioIn Clinic ExerciseHome VisitsHydrotherapy

NDIS Plan Start Date

NDIS Plan End Date

Plan Manager Agency Name

Plan Manager Email Address (For Payment of Accounts)

Name of Contact Person (if you would like us to contact someone other than yourself about your Funding eg Plan Manager/Support Coordinator/Family member)

Phone Number/Email Address of Contact Person

Please upload a copy of your current NDIS Plan

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HOW DID YOU FIND OUT ABOUT US?

Please enter referrers name below *

Please enter source below *

REASON FOR VISIT

Please circle area on the chart below

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Please circle area on the chart below

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Is this problem a New or Ongoing Problem *

New problemOngoing problemFlare up of an old problem

What do you think caused your problem to occur? *

Has your problem been diagnosed by a medical professional previously? *

YesNo

What was the diagnosis and management? *

Have you had any recent or relevant scans on your problem? *

YesNo

From your understanding what did your scans show? *

How long have you had this problem *

Please specify 'other' *

Please rate your current pain level *

Overall are your symptoms *

ImprovingWorseningUnchanging

Wrist Activity Qs

Elbow Activity Qs

Shoulder Activity Qs

Cervical Activity Qs

Thoracic Activity Qs

Back Activity Qs

Hip Activity Qs

Knee Activities Qs

Ankle Activity Qs

Please specify 'other' *

Are you currently off work due to your problem? *

YesNoNot Applicable

Is your problem preventing or limiting you participating in regular non-work activities? eg Sport, Social, Home Duties *

YesNo

What activities is your problem preventing or limiting you participating in? *

Does your problem affect your sleep? *

YesNo

Please Specify *

How many weeks into your pregnancy are you? *

How many previous pregnancies have you had? *

Do you have any particular concerns regarding exercising during pregnancy? *

What is your previous exercise history? *

What delivery type are you planning for? *

Vaginal deliveryC-SectionVBAC (vaginal birth after cesarean)Unsure

Do you have any birth preparation concerns? Please detail. *

How long have you had Pelvic Girdle Pain/Sacroiliac Joint Pain? *

Are there any particular aggravating factors for your Pelvic Girdle Pain/Sacroiliac Joint Pain? Please detail. *

Are there any particular easing factors for your Pelvic Girdle Pain/Sacroiliac Joint Pain? Please detail. *

Are your Pelvic Girdle Pain/Sacroiliac Joint Pain symptoms? *

ImprovingWorseningUnchanging

How Far Post Partum? *

0-6 weeks6-12 weeks12-52 weeks>52 weeks

Delivery Type *

Vaginal deliveryAssisted vaginal delivery (vacuum or forceps)C-SectionVBAC (vaginal birth after cesarean)

Have you had your abdominal separation assessed previously? *

YesNo

What symptoms are you experiencing due to your abdominal separation? *

How long have you had mastitis for? *

Have you had mastitis previously? *

Have you identified any triggers/causes for your mastitis? *

Have you had any past treatments for mastitis? Please detail. *

How long have you had incontinence for? *

Do you know what volume you are losing? If yes please detail. *

Are there any particular triggers/causes for your incontinence? If yes please detail. *

Is your incontinence *

ImprovingWorseningUnchanging

How would you rate your level of concern regarding your incontinence? *

HighMediumLowNot concerned

Are you using any incontinence products? If yes please detail. *

What prolapse symptoms are you experiencing? Please detail. *

How long have you had prolapse symptoms? *

Are your prolapse symptoms - *

WorseningImprovingUnchanging

What factors aggravate your prolapse symptoms? *

What previous management have you had for your prolpase? Please detail. *

Brief History *

Please Upload Any Reports/Referrals Relating to This Concern (If Available)

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ADDITIONAL CONCERNS

Please Specify *

MEDICAL HISTORY

Please detail any relevant information about the above Medical Conditions eg Allergic to Latex *If nil please type 'Nil'

Please List Any 'Other' Medical Conditions below *If nil please type 'Nil'

Please List All Current Medications eg Blood thinners *If nil please type 'Nil'

Are you or could you currently be pregnant? *

YesNo

Have you been advised of any physical restrictions by your obstetrician/midwife?

YesNo

Please provide details *

Have you had any previous pregnancies? *

YesNo

CONSENTS

LATE CANCELLATION & NON-ATTENDANCE POLICY - Three hours minimum notice is required for cancellation of individual and group appointments. Signing below is acceptance that a fee equivalent to the cost of your appointment must be paid for instances of non-attendance or failure to provide more than 3 hours notice of cancellation. *

Yes

PAYMENT POLICY - All accounts with the exception of compensable claims must be paid in full at the time of your appointment. Signing below acknowledges that you agree to pay at the time of your appointment and agree to pay any collection fees incurred by us in recovering unpaid accounts. *

Yes

CONFIDENTIAL INFORMATION RELEASE - To assist in your management we may need to communicate to other parties involved in your management. This may include your Doctor or Claim Manager. Select yes to confirm you authorise release of information relating to your treatment to others involved in your care. *

YesNo

NOTE TAKING - Your practitioner may utilise digital transcription during sessions to aid in accurate note-taking. Do you consent to this? *

YesNo

I am happy to receive notifications from the practice eg appointment reminders and occasional updates. *

YesNo

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature *

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Today's Date *

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