Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Date of birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Mobile*WorkHomeEmail (used for appointment reminders)* Enter Email Confirm Email Occupation Employer Location Do you have private health insurance?* HBF Medibank Bupa AHM HIF GUHealth Police Health Teachers Health Fund HCF Australian Unity Defence Health GMF GMHBA nib Frank Health Insurance CBHS Health.com.au No I don't have private health insurance Your Health Information:Are you a smoker? Yes No GP's Name GP's Practice Location Do you give Bodysmart permission to contact your GP if required? Yes No How did you hear about Bodysmart Health Centre? Google/Bing Yellow Pages Workplace Expo Flyer - Workplace Health Insurance Website Newsletter Flyer - Street Gym Member Internet Search Ergonomic Assessment Doctor (Please specify name and practice location) Friend /Colleague (Please specify full name) Other (Please specify) Doctors Name Doctors Practice Location Friends Full Name Others Are there any songs / artists you can recommend for our clinic playlist? Please indicate if this treatment is Private Consultation Motor Vehicle Injury Department of Veteran Affairs Workers Compensation Injury Enhanced Primary Care (Medicare) PLEASE INDICATE IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING IN THE LAST 6 MONTHS Anxiousness Asthma Sinusitis Leg weak / numbness Severe / acute stress Hand / wrist pain Ulcer Calf cramping Insomnia Constipation Diarrhea Ankle / foot weakness Headache Heartburn Abdominal pain Foot / toe numbness Dizziness Finger numbness Kidney disorder Skin problems Unexplained Nausea High Blood pressure Urinary problems Chronic cough Feel generally unwell Chest pain Loss of taste / smell Shortness of breath Pain that wakes you at night Sad for more than 1 week at a time Your Symptoms Please indicate your main areas of pain by circling the diagram below:Please list and date any INJURY, ILLNESS or SURGERY (including cosmetic) you are currently (or previously) had:Please list all medications and/or vitamins/supplements you are currently takingPlease indicate two priority objectives you would like to achieve from your consultation todayHave you seen another Physio / Chiro in the last 6 months? Yes No If yes, at which location Approximate Date DD slash MM slash YYYY Have you had any X-Rays / scans in the last 5 years? Yes No Have you had an ergonomic assessment of your workplace in the past 6 months? Yes No If yes, was it by a Bodysmart Practitioner? Yes No Would you like to receive our FREE quarterly health and wellbeing e-bulletin? Yes No Would you like to receive a link to our Facebook page? (Giving you occasional special offers and updates) Yes No Would you like further information about the following Bodysmart Products / Services? Physiotherapy Remedial Massage Chiropractic Clinical Pilates Clinical Strength Group Pilates Group Functional Training Group Stretch & Roll Corporate Health Ergo Products (Please Check) Ergo Products Sit-Stand Desks Chairs Keyboards Cancellation Policy In the interest of other patients who may miss the opportunity of an appointment they may need, and to ensure appointments run on time, an Appointment and Cancellation Policy applies to all appointments. *** PLEASE READ APPOINTMENT AND CANCELLATION AGREEMENT (PAGE 3) INTRODUCED 2011 *** I have read and I agree to the terms and conditions of Bodysmart’s Appointment and Cancellation Agreement. I understand that if I fail to attend, or fail to cancel a scheduled appointment with less than 4 hours notice I WILL pay a cancellation fee. PATIENT’S SIGNATURE*Date DD slash MM slash YYYY CAPTCHAPractice Information and Cancellation Agreement The following policies (implemented in October 2011) apply to all appointments at our practice in order to help us provide you with exceptional service and help us to respect and improve the standard of our service to ALL of our valued clients and practitioners. Pay on the DayBodysmart is a strict "pay on the day" practice, including all initial appointments for private consultations and Motor Vehicle (ICWA), DVA and Workers Compensation claims. If payment is not made on the day a $5 administration fee will apply. In the case of insurance claims, with a valid GP referral, other supporting documentation and approval from your insurer you may be able to claim a rebate for consultation fees through your employer’s Workers Compensation fund or ICWA. Payment MethodsBodysmart offers HICAPS facilities, which enables you to swipe your participating health insurance card (e.g. Medibank, HBF MBF etc) and obtain an instant rebate. Gap payments can be made with EFTPOS facilities or cash. Bodysmart accepts most credit cards except AMEX and DINERS. Cheque payments are not accepted. Health CoverageAll Bodysmart practitioners are registered with most Private Health Funds. Please ensure that you have checked with your health fund to ensure coverage for the applicable service prior to your appointment. Bodysmart can not accept responsibility for any errors or misunderstanding between patients and health funds regarding rebates. Late Arrival PolicyWe regret that late arrivals may not receive an extension of their scheduled appointment and will be charged in accordance with their scheduled appointment as this time has been allocated to you. In special cases, and when our schedule will allow, we may be able to accommodate a partial or full appointment. This will be at our discretion and will only occur with proper, advanced notification of your late arrival. If your therapist is running late, due to unforeseen circumstances, you will receive your full scheduled appointment allocation. Cancellation and Failure to Attend PolicyBodysmart ENFORCES the following cancellation policy:4 hrs notice – no fee payable, we sincerely appreciate your advanced notice.0-4 hrs notice – 75% of the consultation fee payable*.Failure to attend a scheduled appointment – 100% of the consultation fee payable*.* As you did not attend your appointment in these cases we can’t allow a health fund rebate to be claimed for this fee. You will be required to clear all fees prior to attending your next appointment with us. Remembering your AppointmentAll appointments with all practitioners are to be in written on a card. It is your responsibility to keep their appointment card safe, and arrive at the time stated on the card. Unfortunately Bodysmart cannot be held responsible if you fail to attend an appointment if you lose your card. Bodysmart offers a courtesy email reminder system, however this is not intended to substitute the card written appointment. This system is provided by a 3rd party provider and therefore we do not have total control over its reliability. Thank you for taking the time to read this information, and for entrusting us with your care.