Young sportsperson assessment request

Young person's Name

First NameLast Name

Birth date

Date

What is the primary sport played ?

Parent/ Guardian Details

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

How you where referred to us?*

What is your reason for requesting this appointment?

We consult Monday -Thursdays. Please indicate preferences of days/ times

Please be aware that by filling out the information on this form you will not be added to any list or database at this point and it is simply for our team to be able to contact you to discuss your request to book your young person for a screening consultation.

A "screening consultation" means that Dr Paula gathers some health history, performs some tests and observations and provides feedback. It is offered at a special price for participants of her "Strong, Resilient, Brave" program. The cost is $60 (normally $120). The appointment can also be claimed via PHI.

There is no treatment included in this assessment appointment.

Please note, if you do book an appointment you will be asked to secure your booking with a credit card deposit. If you cancel your appointment without notice this will serve as a cancellation fee.

There is no obligation to proceed with further consultation unless there are some issues identified that you wish Dr Paula to assist with for your young person in the future.

I understand the above statement and give permission to be contacted

Signature

Please verify that you are human*