Initial Intake and Consent Form

Health Conditions

To assist your physiotherapist in providing a SAFE and EFFECTIVE treatment please indicate if and when you have had any of the following conditions. rn

I consent to have treatment once it is adequately explained to me by the physiotherapistrn
I Understand that if acc decline my claim I am liable to pay for all physiotherapy fees.rn
Payment for treatment is due on the same day, Unless prior arrangements have been made.rn
If I fail to notify the clinic at least two hours in advance to cancel a scheduled appointment, I understand that there is a non-attendance fee to pay of $30.00rn
I understand that I am liable to pay ACC co-payment of $35.00 for the first consultation and $30.00 for any consultation thereafter.rn
ACC Telehealth consultation co-payment fee $20.00rn
Telehealth Private Charges (No- ACC) $45.00 rn
Private Charges (Non-ACC) $75.00

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