PATIENT REGISTRATION FORM

Enter N/A if none
e.g. neck, shoulder, lower back

Clear drawing
Tick all that apply
1 - No pain, 10 - worst pain

Activity or exercise.  How often do you do these exercises?


HAVE YOU EVER HAD, OR RECEIVED ADVICE OR TREATMENT FOR ANY OF THE FOLLOWING:


This practice operates in accordance with the Privacy Act – please refer to the attached clipboard for further details. (If the patient is younger than 18 years, consent must be provided by a guardian/parent.)

Personal Health information and my health record. May be used and disclosed for the following reasons; for communication with treating medical professionals, for follow up/reminder calls, for discussion with third party insurers, accounting/Medicare/health insurance procedures, disease notifications as required by law, for use by all practitioners to this practice when consulting with you and for legal disclosure as required by a court of law. A full National Privacy Policy is available for your perusal at www.privacy.gov.au

This practice reserves the right to charge a fee for cancellations within 24hrs of your scheduled appointment (50% of appointment fee) and failure to attend without notice (100% of appointment fee). By signing this form and proceeding with treatment you agree to be bound by these terms.


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PERFORMANCE PODIATRY

(07) 3846 4800
Suite 2B, 90 Vulture Street
West End, Queensland 4101
www.performancepodiatry.com.au