JC Physiotherapy Expression of Interest Form

Physiotherapy Expression of Interest

With Joshua Carpenter
Josh is a qualified Physiotherapist who has completed a Bachelor of Physiotherapy as well as a Bachelor of Sports and Exercise Science at the University of Canberra. Over the past few years, he has been fine-tuning his craft in the private practice setting, working with a wide range of children and adults for various injuries and conditions.

He will be joining the Canberra Development Clinic in January 2025 as our first physiotherapist. Josh will be seeing clients aged 6 to 17 for children and 18 to 80 for adults. We are currently taking a waitlist for appointments.

Please complete this form if you are interested in seeing a physiotherapist at the Canberra Development Clinic.
Patient's Name*

First NameLast Name
Patient's DOB*

DayMonthYear
Parent / Guardian Name *if applicable*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Have you seen a physiotherapist previously?*

YESNO
Why are you seeking for physiotherapy from us? *
Terms and Conditions of Care and Treatment

You have requested to be on a waitlist to see a physiotherapist. This requires information from within the family, school, other therapists that work with the child and any other systems that influence the child. Please read carefully through the following statements and sign below if you agree to all of them.
I understand that the medical information collected at the practice will be used to provide clinical care, administrative purposes, to record your health information, billing purposes, including compliance with Medicare and insurance requirements. It may be necessary to disclose this information to fulfil medical insurance obligations.*

Yes
I consent to be contacted about my child's potential involvement with Josh, physiotherapist, using the information I have provided*

Yes
Name *

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Should be Empty:

Physiotherapy Expression of Interest

Terms and Conditions of Care and Treatment