New Client Form

Name*

Prefix First Last

Date of birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile*

Work

Home

Email (used for appointment reminders)*

Enter Email Confirm Email

Occupation

Employer

Location

Do you 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?

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

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 taking

Please indicate two priority objectives you would like to achieve from your consultation today

Have you seen another Physio / Chiro in the last 6 months?

Yes
No

If yes, at which location

Approximate Date

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?

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

CAPTCHA

Practice 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 Day
Bodysmart 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 Methods
Bodysmart 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 Coverage
All 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 Policy
We 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 Policy
Bodysmart 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 Appointment
All 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.

Cancellation Policy

Practice Information and Cancellation Agreement

Pay on the Day

Payment Methods

Health Coverage

Late Arrival Policy

Cancellation and Failure to Attend Policy

Remembering your Appointment

We accept all private health funds

Be in the know

Contact us now