Consent Form Name First Name Last Name Address Your Address City State Postcode Your Mobile Your HOme Number Email GenderMaleFemaleOtherD.O.B. DD slash MM slash YYYY Occupation Emergency Contact Name and Phone GP Name and Address Funding: PrivateYesNoHealth Fund DVA Y N NDIS Y N CHSP Y N HCP Y N How did you hear about usFriendFamilyGoogleFacebookInstagramDoctorSpecialistOtherIf Friend or Family are you happy to tell us who so we can thank them? Please tick YES or NO for the following:Diabetes Y N Asthma, COPD, COVID or respiratory conditions Y N Epilepsy or Seizures Y N Neurological Disorders, Anxiety, Depression Y N High Blood Pressure Y N Heart Disease Y N Do you smoke Y N Are you pregnant Y N Broken bones, sprains, dislocations Y N Arthritis - Osteoarthritis, Rheumatoid, Juvenile Y N Recent surgery, or hospitalisation Y N Headaches, migraines, concussion Y N MedicationsMedical/Surgical HistorySports/ActivitesConsent 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) Consent Accept termsCancellation Policy Thank you for choosing Gold Coast Sports Medicine & Rehabilitation for your therapy needs! We are happy to be helping you on your journey to better health and fitness and know that sometimes plans change, and clients need to cancel or reschedule an appointment or class booking. We ask that you contact us as soon as possible, with a minimum of 24 hours’ notice before your scheduled appointment time. This provides the practice with the opportunity to offer the spot to other clients who are waiting for an appointment. Failure to notify the clinic of a cancellation or reschedule with more than 24 hours’ notice will result in a fee. • Appointment cancellations within 24 hours a fee totalling 50% of the scheduled appointment cost will be debited at your next appointment. • Appointment cancellations within 4 hours, the full fee charge will be added to your account and debited at your next appointment. • Class cancellations within 24 hours, a $10.00 fee will be added to your account and debited at your next appointment. • Class cancellations on the day of, will lose 1 class from your pack or be charged the full fee from the class, which will be added to your account and debited at your next appointment. All patients will be given one warning of the cancellation policy. This amount is payable before the clinic is able to make further appointments for the client. For all NDIS, Home Care, or third party patients, please refer to your individual service agreements for the cancellation policy that applies to your treatment. We understand that extenuating circumstances sometimes occur, and consideration will be given to these clients at the clinician’s discretion. Thank you for respecting our clinician's time, and the needs of other patients who may be waiting weeks to get an appointment with the therapist of their choice. By giving us as much notice as possible, it allows GCSMR to look after all our clients to the best of our ability.
