Name *

First Name

Last Name

Please tick if you have had a history of any of the following

Heart attack / angina

Pace maker

Deep vein thrombosis

High Cholesterol

Diabetes

Recent blood loss

Rheumatoid arthritis

Osteoarthritis

Vertigo / Dizziness

Loss of consciousness

Vision impairment

Hearing impairment

Sensation loss

Cancer / tumor

Chemotherapy

Radiation

Unremmitting night pain

Surgery

Extreme fatigue

Headaches / Migraines

Cauda equina syndrome

Bladder / bowel dysfunction

Immunosuppression

History of a traumatic fracture

Pelvic region numbness

Stroke

Shingles

Spondylolisthesis

Sudden unexpected weightloss

Please tick to verify you agree to the following *

You consent to undergo a video or telephone consultation with one of our Physiotherapists. You understand that our therapists will refer you on if they deem it neccessary. Video consultations have limitations in treating certain conditions, you concent to recieving a phone call prior to your appointment to ensure you are suitable for a consultation (if the therapist deems it neccessary from your above answers). If you are not suitable a full refund will be applied to the bank account you used to pay for the consultation. You agree to the release of relevant medical documentation to work cover, TAC and your GP (if applicable). Cancellations require 24 hours notice for cancellation (unless there are extreme curcumstances) otherwise we will be unable to issue you a refund. If you are a work cover, TAC or Medicare covered patient, and your cover is denied, you will be responsible for the payment of the consultation. By checking the above box you consent to the above.