Consent Form : The Corrective Clinic

To submit your Consent Form, please fill in your details below and click the Submit button.
Please note all fields are required & your details will be kept strictly confidential.

Full Name

Date of Birth

Address

Contact Ph

Emergency Contact

Please tick the box if you have or have had any of the following issues:
TuberculosisHIV/AIDSHepatitis/DisorderHeart ConditionSlipped Disc or Back TroubleDizzinessIssues With Swallowing/EatingAllergiesNeck PainFeverRecent Weight LossNumbnessShaky EyesNauseaPneumonia or PleurisyAsthmaRheumatic Fever (Rheumatism)DiabetesArthritisSurgery/Joint ReplacementNeuralgiaHigh or Low Blood PressureEpilepsyFainting or MigraineSciaticaCancerMental IllnessOther

Are you Pregnant?YesNo

Do you have any known disease or infection that can be transmitted through bodily fluids?YesNo

Has your doctor ever told you that you have a heart condition or have you ever sufered a stroke?YesNo

Do you ever experience unexplained pains in your chest at rest or during physical activity or exercise?YesNo

Do you ever feel faint or have spells of dizziness during physical activity or exercise that causes you to lose balance?YesNo

Do you have diabetes (type 1 or type 2), have you had any trouble controlling your blood glucose in the last 3 months?YesNo

Do you have any physical or medical condition(s) that may make it dangerous to participate in physical activity or exercise?YesNo

What are your interests?
GymGym classesRunningYoga/MobilityCrossfitOther

How did you find us?
FacebookGoogleWebsiteReferralLes MillsLes Mills P.T.ChiropractorPodiatristG.POther

Your Doctors Name

Doctors Full Contact Details

Terms and conditions – Please read and confirm below:

PAYMENT in full will be made at the end of each treatment session. The clinic accepts cash, eftpos and credit card or you can make secure
payment via online services (enquire for account details). In the case where ACC funding is denied/declined I accept full responsibility for
funding of the physiotherapy services provided. ‘All costs incurred in the recovery of overdue funds including but not limited to debt
recovery charges and legal fees may be added to the balance of your account.’

CANCELLATION can be made with no charge if a minimum of 24 hours notice is given. Please note ACC does not cover cancellations, i’e.
failure to notify within this time will incur a full cost of the service booked (our surcharge and the ACC component). Cancellation fees will be
charged as follows: 1 hour session $60. 30 minute session $30.

CONSENT TO TREATMENT; STATEMENT:

I agree to give my consent to treatment from The Corrective Clinic as discussed by my therapist and reserve the right to refuse treatment at any time.