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Welcome. We want you to feel respected and safe.
First name
*
Surname
*
Address
*
City, town or suburb
*
Post Code
*
Date of Birth
*
Date
Format: 09/12/2021
Phone (fixed line)
Phone (mobile)
E-mail
*
A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.
Select any of the following that apply to today’s appointment
Veteran Affairs
WorkSafe
TAC
EPC - full payment is required and then we are happy to process your medicare rebate on the day of treatment
NDIS - you must supply a current NDIS Plan before your appointment.
Select all that apply.
Parent's Name (if coming for your child)
GP Name
GP Address
Specialists Name
Specialist Address
Other people involved in your care
please list all other relevant people involved in your care such as other medical/allied health provider, NDIS support coordinators and agency or personal trainer
What is the reason you have come to see us today?
*
Who suggested you attend Innerstrength physiotherapy?
Friend
GP
Specialist
Other
You can select more than one.
Release of private health information.
*
I do not consent to sharing my personal information.
I consent to written and verbal communication with my GP.
I consent to written and verbal correspondence with my specialist/s.
I agree to pay the cancellation fee
*
Would you like to receive a free appointment reminder via SMS?
*
Yes
No
** Please note it is your responsibility to attend the appointment with or without the reminder.
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