PHYSIOTHERAPY NEW PATIENT FORMComplete Online Form HerePatient DetailsFirst NameLast NameDate of BirthAgeMobileEmailStreet AddressCityStatePostcodeName of DoctorPractice LocationName of Private Health FundHow did you hear about AMS?How did you find out about Active Movement Studio?*How did you find out about Active Movement Studio?GoogleFacebookInstagramFlyerPromotionWord of mouthDoctor referralMedical/Injury History & MedicationWhat is your reason for your consultation?List any previous injuries that have required treatment in the pastMedicationAre you currently taking any prescription medications?YES - complete list belowNOList of medicationsName of MedicationDoseReason for Prescription Exercise HistoryAre you currently engaging in regular structured exercise?AnswerYES - please list belowNOWhat type of exercise are you engaging in, past or present?WorkWhat is your current occupation?How many hours per day do you spend seated? 0 - 2 2 - 4 4 - 6 6 - 8Goals & OutcomesTreatment Goals (set up to 3 goals per category)Immediate (>1 week)Short Term (<3 months)Long Term (>6 months) Patient Information & ConsentInformed Patient Consent Select All As a patient you may be required to remove certain articles of clothing to allow for a detailed musculoskeletal assessment You may withdraw your consent at any time Risks will be explained prior to treatment at which time you may choose to continue to discontinue with treatment I hereby acknowledge that all the information I have provided to Active Movement Studio is accurate to the best of my knowledge. If unsure of any information I will inform my practitioner. As a patient of Active Movement Studio it is my responsibility to notify my practitioner if there are any changes to my medical condition including changes in medication. I give permission for Active Movement Studio to contact my general practitioner or other allied health professionals to obtain any relevant information regarding my condition.Privacy Policy Active Movement Studio is committed to ensuring that all personal information that is disclosed in consultations and sessions will remain confidential and only be accessible by appropriate staff. All personal information is stored in a secure location protected from unauthorized access, modification or disclosure. All staff are regularly reminded of the importance of this matter and any breach in privacy is not tolerated.AMS Rescheduling Policy* Select All Your reserved consultation time has been specifically allocated to you. To achieve maximum improvements in the shortest possible timeframe, it is vital that you maintain your advised schedule of care. If you are unable to make your appointment time, please note the following applies: Did Not Arrive (no courtesy call or notification) = 100% Fee Applies Cancellation within 24 hours = 50% Fee Applies Cancellation within 6 hours = 100% Fee Applies Upfront Packages - Cancellation with 24 hours = 100% Fee Applies Our AMS Rescheduling Policy aligns with our core value ‘To positively impact as many lives as possible’. Sufficient notice enables us to make the appointment available to someone else. We thank you for your understanding and cooperation.Let's Stay Connected I give AMS permission to register me to receive exclusive promotions, free health advice, hear the latest fitness trends, access our workout of the month and gain exclusive invitations to our workshops and more.Consent to Treatment* I have read and understand the above information, including the AMS Rescheduling Policy, and give my consent to treatment. I agree to this consent remaining valid until such time as I withdraw my consent. I also agree and give consent for my case to be discussed with AMS practitioners, treating doctor and 3rd party bodies if appropriate.Sign Here*
