Patient Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I wish to be reminded of my appointment via text messaging

Yes

No

Name *

First Name

Last Name

Please tick any that apply:

Diabetes

Asthma/Respiratory Condition

Cardiac Condition

Epilepsy

HIV/Hepatitis C

Cancer

Artificial Implants

Hearing/Sight Impaired

Pregnant

Smoker

Allergy/Reaction eg. tape

Osteoporosis

Rheumatoid Arthritis

Acupuncture Reaction

Other - please specify:

Do you have any individual needs, cultural needs, beliefs & values that need to be addressed?

Yes

No

Date of injury *

MM

DD

YYYY

Time of injury

Hour

Minute

Second

AM PM

Was this injury work-related?

Yes

No

Was this a motor vehicle accident?

Yes

No

I hereby agree that: *

I consent to treatment by an appropriately qualified Physio/Hand Therapist for the purpose of providing comprehensive hand therapy or physiotherapy services as may be deemed necessary in support of my illness, injury or condition.

I have been given the opportunity to read clinic information, either in the clinic or on the Mahurangi Physio & Hand Therapy website at www.mahurangiphysio.com, prior to treatment.

I understand that I have the right to decline part or all of the treatment being offered.

I understand my right to a second opinion.

I understand that I am liable to pay for: *

Any treatment that is declined by ACC or other funder

The costs of materials for Physiotherapy such as braces, materials, products etc. A parent/guardian will be notified first if a cost is involved, so they have the choice to proceed or not. Hand Therapy splinting in most instances is covered by ACC

I understand that if this service requires engaging a Debt Recovery Service to recover my debt, I will be liable for any recovery fees

I consent to: *

Mahurangi Physio & Hand Therapy requesting information from a third party, and/or disclosing information to a 3rd party in regards to my condition. These actions will be taken only when necessary for the effective management of my condition.

Clinical records being sent to my doctor, medical centre, or funding provider in regard to my treatment.

If registered with ACC, or an accredited insurer, I authorise for ACC, or an accredited insurer, to collect medical and other records which are or may be relevant to my treatment.

A discharge/update report being sent to my doctor or medical centre.

*

I DECLARE – That the information I have given in this form is true and correct, and I’ll tell ACC if my situation changes.

I AUTHORISE – The treatment provider to lodge this ACC claim for me; and authorise for my records to be collected or disclosed to ACC to help determine cover for my claim, determine what I’ll be entitled to, or for research purposes (such as injury prevention, or assessment, and rehabilitation).

TYPE NAME TO CONFIRM CONSENT: (If student under 18, parent/guardian name mandatory) *

First Name

Last Name

DATE: *

MM

DD

YYYY