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Please fill in the ONLINE FORM below or DOWNLOAD, print, fill out and bring to your appointment.

GCSMR Consent Form: Download Form >>>>  or fill in the Online Form below.

    First Name
    Last Name
    Your Address
    Your Mobile
    Your Home Number
    Email Address
    Emergency Contact Name and Phone
    GP Name and Address
    Funding: Private
    Health Fund
    How did you hear about us
    If Friend or Family are you happy to tell us who so we can thank them?
    Please tick YES or NO for the following:

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

    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.

    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)

    we are here to support you.

    Consent Form