NEW PATIENT FORM

Before commencing Allied Health (Physiotherapy, Chiropractic, Exercise Physiology, Occupational Therapy, Psychology, Speech Pathology, Dietetics, Podiatry & Massage Therapy) treatment at JT Physio  (ABN: 85 600 024 619): 

A Doctor’s  referral and your Medicare Card are required (for Medicare patients only).

I understand that I will be receiving physical therapy and/or other allied health services and that the purpose of these services is to address my individual and specific health needs. I acknowledge and understand that while physical therapies can offer numerous benefits, there are also inherent risks involved. These may include but are not limited to soreness or discomfort after treatment sessions.

As part of the service(s) provided, your service provider will collect and record personal information from you that is relevant to your treatment. You do not have to give all your personal information, however, withholding information may impact the treatment provided to you. Information is gathered as part of the assessment, diagnosis and treatment of your condition, and is seen only by the treating service provider. You are entitled to access your file at any stage, unless the relevant legislation provides otherwise.

Confidentiality:

All personal information gathered by the service provider during the provision of the service will remain confidential and secure except where:

• Failure to disclose the information would place you or another person at serious risk of harm. Your service provider has a duty of care to yourself as well as others in the community to prevent any serious risk of harm where it is possible to be prevented.

• Your file is subpoenaed by the court.

• A serious crime is being committed by you someone you know.

• Your permission is obtained to discuss or provide a written report to another professional, agency or person e.g. GP, lawyer, or parent.

• If disclosure is otherwise required or authorised by law, such as in cases of child protection laws.

Cancellation Policy:

You are requested to give a minimum of 24 hours notice when cancelling or changing a scheduled appointment time.

Failure to notify us within this time frame will result in a $80 Cancellation/DNA fee being charged.

Update News, Emails and Messages Consent:

JT Physio  may send messages to remind you of your appointments. We may also send update news and important clinical information to you via messages or emails. If you no longer wish to receive messages or emails from us please contact us directly on our landline number, or you may notify us via email.

Purpose of collecting and holding information:
This information is gathered as part of the assessment, diagnosis and treatment of the patient’s condition, and is seen only by the service provider. The information is retained in order to document what happens during sessions, and enables the service provider to provide a relevant and informed service.

Access to patient information:

At any stage, you as a patient, are entitled to access to the information about you kept on file, unless the relevant legislation provides otherwise. The service provider may discuss with you regarding appropriate forms of access.

Telehealth:

Telehealth service is a way for you to have a consultation over video or phone. The service provider uses systems that meet recommended standards you protect your privacy and security. You can change your mind and stop the conferencing at any time, including during the consultation. By signing this form, you agree to conduct telehealth consultations with our allied health service provider(s) as a secondary option.

Before commencing Allied Health (Physiotherapy, Chiropractic, Exercise Physiology, Occupational Therapy, Psychology, Speech Pathology, Dietetics, Podiatry & Massage Therapy) treatment at  JT Physio  (ABN: 85 600 024 619):

A  Doctor’s Referral and  Certificate of Capacity/Fitness or Workers' Compensation Medical Certificate is required (where applicable).

As part of providing an allied health service to you, our service provider will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the assessment and treatment that is conducted. You do not have to give all your personal information, but if you don’t, this may mean the allied health service may not be able to be provided to you.

You are required to provide correct information regarding the following:

• Your address and phone number (notify us of any changes)

• Details of your injury including date and place

• Employers details including name, address, and phone number (if applicable)

• Insurance details including company name, claim number, and case manager name

• Contact person handling the claim (if applicable)

A claim form must be submitted to the insurance company within the specified timeframe.

You are requested to keep in contact with your insurer to ensure the claim is being processed. It is important that you notify us immediately of:

• Your claim number

• Any doubt or denial of liability of your claim by the insurance company

• Any litigation (court action) arising from your claim.

Failing to adhere to the above may lead to persons receiving allied health services at  JT Physio being responsible for all costs  incurred for assessment, treatment and any other related expenses incurred and also in the event that:

• Your insurer denies liability

• If there is no record of a claim lodged with the nominated insurers

Should you have legal representation (solicitors/lawyer) for your claim, you will consent and  irrevocably authorise your legal representative (solicitor/lawyer) to pay the outstanding amount to  JT Physio at the completion of your claim.

Confidentiality:

All personal information gathered by the service provider during the provision of the allied health service will remain confidential and secure except where:

• It is subpoenaed by a court; or

• Failure to disclose the information would place you or another person at serious an imminent risk; or

• It is involved in serious crime; or

• Your prior approval has been obtained; or

• We provide a written report to another professional or agency. Eg. GP or a lawyer; or

• If disclosure is otherwise required or authorised by law.

Physical Examination (if applicable):

Part of a service provider’s clinical assessment and decision-making process can be assisted by a physical examination in addition to a discussion with you. The service provider may need to examine the area of injury and associated areas by:

• Asking you to remove appropriate clothing to allow examination of the area;

• Touching and treating the area(s) of injury and other areas that may be related (occasionally under clothing, or covered by a towel, if appropriate)

If for any reason and at any point in time, you feel uncomfortable or embarrassed, please advise the service provider and this will be stopped immediately. The service provider will work with you in other ways, understanding there may be limitations in the results achieved.

Cancellation Policy :

You are requested to give a minimum of 24 hours notice when cancelling or changing a scheduled appointment time.

Failure to notify us within this time frame may result in the  full treatment fee being charged .

Update News, Emails and Messages Consent:

JT Physio  may send messages to remind you of your appointments. We may also send update news and important clinical information to you via messages or emails. If you no longer wish to receive messages or emails from us please contact us directly on our landline number, or you may notify us via email.

Purpose of collecting and holding information:

This information is gathered as part of the assessment, diagnosis and treatment of the patient’s condition, and is seen only by the service provider. The information is retained in order to document what happens during sessions, and enables the service provider to provide a relevant and informed service.

Access to patient information:
At any stage, you as a patient, are entitled to access to the information about you kept on file, unless the relevant legislation provides otherwise. The service provider may discuss with you appropriate forms of access.

Telehealth:

Telehealth service is a way for you to have a consultation over video or phone. The service provider uses systems that meet recommended standards to protect your privacy and security. You can change your mind and stop the conferencing at any time, including during the consultation. By signing this form, you agree to conduct telehealth consultations with our allied health service provider(s) as a secondary option.

I have read and understood the above information and agree with these conditions for the allied health service(s) provided by  JT Physio. By signing this form, I also give permission to  JT Physio to release information regarding my treatment to my referring doctor and any other persons that I nominate. 

I understand I may withdraw my consent at any time and I will need to do this in writing. I provide consent for the release of information to:

Please Note: If, after reading this page you are at all unsure of what is written, please discuss it with our administration staff or service provider.