First Name

Last Name

Your Address

City

State
Choose a StateQLDNSWVICTASSAWANT

Postcode

Your Mobile

Your Home Number

Email Address

Gender
Your GenderMaleFemaleOther

D.O.B

Occupation

Emergency Contact Name and Phone

GP Name and Address

Funding: Private
Select optionYesNo

Health Fund

DVA YN
CHSP YN

NDIS YN
HCP YN

How did you hear about us
Select option:FriendFamilyGoogleFacebookInstagramDoctorSpecialistOther

If Friend or Family are you happy to tell us who so we can thank them?

Please tick YES or NO for the following:

YesNo | Diabetes
YesNo | Asthma, COPD, COVID or respiratory conditions
YesNo | Epilepsy or Seizures
YesNo | Neurological Disorders, Anxiety, Depression
YesNo | High Blood Pressure
YesNo | Heart Disease
YesNo | Do you smoke
YesNo | Are you pregnant
YesNo | Broken bones, sprains, dislocations
YesNo | Arthritis - Osteoarthritis, Rheumatoid, Juvenile
YesNo | Recent surgery, or hospitalisation
YesNo | Headaches, migraines, concussion

Medications:

Medical / Surgical History:

Sports / Activities:

Consent to Treatment
I'm of sound mind make the informed choice to participate in an ongoing therapy program conducted by Gold Coast Sports Medicine and Rehabilitation. I understand all that is written on this document and have given an honest and complete account of my history. I consent to assessment, treatment, and the possible use of videography for assessment and treatment purposes only.

Confidentially
I agree to grant permission for Gold Coast Sports Medicine and Rehabilitation to disclose, where reasonably necessary, any required medical and personal information to third parties including: general practitioners, other physiotherapists, hospitals, insurance agencies acting on your behalf and other health professionals in the event that reasonable information is required in an attempt to provide for my optimal health and physical progression.

Parental / Guardian Consent:(Only for patients under 16)

Accept terms