Patient Information & Consent Form for ACC & Private Physiotherapy Treatments
Client Information Section:
Name
*
Select
Mr
Mrs
Miss
Ms
Dr
Master
Title
First Name
Last Name
Known As
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Mobile
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
Suburb
Zip Code
Ethnic Group
Medical Centre
GP
Why did you choose us?
Please Select
Friend/Family
Eastside Physio
Internet Search
Location
Fraser Tech Netball
Suburbs Rugby
Advance Wellness
Existing/ Previous Client
Social Media
GP/Specialist Referral
Street Signage
Emergency Contact Name
Emergency Contact Phone
Relation to you
Please Select
Partner
Parent
Sibling
Aunt/Uncle
Child
Friend
Neice/Nephew
ACC OR PRIVATE INJURY DETAILS
Date of Accident
-
Month
-
Day
Year
Date
Time of Accident
Hour Minutes
AM
PM
AM/PM Option
What have you injured & how did it happen
Location/ Scene
Eg. Home, Work, Gym
Have you completed an ACC Claim for this injury elsewhere?
Yes
No
If yes, where?
if yes, ACC claim number (if known)
Have you received Physio for this injury?
Yes
No
If yes, where?
Did the accident happen at work?
Yes
No
if yes, Workplace Name
if yes, Workplace Address
if yes, Workplace Phone
If the accident happened at work, does your workplace have an insurer?
Yes
No
Unknown
If yes, who?
Please Select
Gallagher Bassett
Work AON
Well NZ
Other
Unknown
Eg. Accredited Employer/ Insurer
EMPLOYER DETAILS
Occupation
Employer Phone
-
Area Code
Phone Number
Employer Business Name
Employer Business Address
Street Address
Street Address Line 2
City
Suburb
Zip Code
Work Intensity
Please Select
Light
Medium
Sedentary
Heavy
HEALTH INFORMATION
Please select if any of the following apply to you
Pregnant
HIV or Hep C
Cancer
Cardiovascular Condition
Skin Infection
Diabetes
Hearing or Sight Impairment
Physical Disability
Other
Medication/s or other information
EMAIL & TEXT REMINDER POLICY
I would like to receive text reminders for my appointments
Please Select
Yes
No
I would like to receive updates via email
Please Select
Yes
No
AGREEMENT TO PAY
CONSENT TO ASSESSMENT / TREATMENT
CONSENT TO RELEASE INFORMATION TO A THIRD PARTY
ACC45 DECLARATION
I DECLARE That the information I have given about this claim is true and correct and that I have not withheld any information likely to affect my claim.
Print Full Name
First Name
Last Name
Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
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