NEW CLIENT FORM

Contact Information

Title

First name *

Last name *

Preferred name

Date of birth *

Email Address *

Home phone

Mobile phone

Sex/Gender *

Gender identity

Street number and address *

City *

State *

Post code *

Country *

How did you find out about us?

Emergency Contact Information

Emergency contact *

Phone *

Emergency contact’s relationship to you *

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Health Information

What are you seeing us about? *

Have you seen a health professional in the past for these conditions?

YesNo

Doctor *

Do you have a referral for your appointment? (Medicare/DVA)

Medicare number

Medicare reference number

DVA card number

Reference number

Do you have private health insurance? *

Please list any medications you are currently taking

Medications

Dose

Please list any allergies

Allergy

Severity

Please list any surgeries

Surgery

Date

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Communication preferences

I want to receive booking confirmation emails. Booking confirmation emails are sent when an appointment is created. *

Cancellation policy

This clinic has a 12 hour cancellation and failure to attend policy that applies to all appointments. Failure to provide 12 hours notice when changing or cancelling appointment times and missed appointments will result in being charged a cancellation fee. *

Privacy Policy

Do you consent to our privacy policy?
In delivering our range of services and support, Intrinsic may gather,store, process, or share your personal information. We are deeply committed to protecting your privacy, and we manage your personal data in strict compliance with the Privacy Act. You can access a complete version of ourPrivacy Policy on our website, or bycontacting us at (03) 5255 5792. *

Consent

I consent to treatment and will act in accordance with the professional instruction and advice as discussed with my practitioner. I acknowledge that there are some risks associated with any healthcare treatment and the information I have provided to my practitioner is correct and current to the best of my knowledge. I agree to keep my practitioner updated as to any changes in my medical condition and understand that there shall be no liability on the practitioner or clinic’s part should I fail to do so. If I experience pain or discomfort during the session, I will immediately inform my practitioner so that he/she can adjust the resistance or technique being used. I wish to rely on my practitioner treating me to exercise his/her judgment during the course of my treatment in such a manner and to the extent that he/ she feels at the time, based on the facts then known, is in my best interests. The practitioner can recommend referral, or decline to treat, if deemed appropriate. As a client, I have the right to withdraw my consent to treatment at any time. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, I will be reported and I will be liable for payment of the scheduled appointment.
*

Signature *

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Date

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