Physiotherapy Referral Form

Physiotherapy is an effective and safe form of therapy. However, like most interventions along with the sought benefits of treatment there are possible side effects, and responses to treatments are unique per individual. Your physiotherapist will provide you with information about a treatment, along with the associated risks and benefits. Our physiotherapists are skilled and should be able to offer a variety of treatments to ensure you get results in a way that you feel comfortable with. This form is designed to inform you of your rights as well as to obtain your consent. You may choose to withdraw your consent at any time for whatever reason. This practice is committed to complying with the Privacy Act 1998 and the Australian Privacy Principles 2014. Please refer to our Privacy Policy, attached to the clipboard, for further details.

Mobile Phones

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Individual Response

Every individual has a unique rate of healing and response dependent on many factors, such as health, co-morbidities, periods of adequate rest etc. If you are concerned about your response to treatment, you are encouraged to discuss this with your physiotherapist.

Referrals

Word of mouth referrals are a great compliment and ensure the success of this clinic. We greatly appreciate your referrals of family and friends. Furthermore, if you have suggestions, comments, or complaints, we encourage you to inform our staff or submit in writing.

Accounts/Fees

Private patients are required to cover their fees at the time of service. We do not HICAPS facilities for the private health insurance so patient will need to prepay for treatment session. Invoice will be given which can be used to claim from private health cover demanding on your level of health cover. Work Cover and DVA clients’ accounts will be sent directly to the appropriate body as required.

Scheduling and Miss Appointments

Physiotherapist will develop a plan with you that takes into consideration your lifestyle and goals of treatment. It is of benefit to you that you are able to schedule your appointments in advance to ensure you can adhere to the plan to the best of your ability, as well as reserving a place in the physiotherapist’s schedule. Although we will do our best to reschedule, missed appointments can delay your recovery. If an appointment must be changed, 24hours notice is required, Failure to give 24 hours of notice attracts full nonrefundable/transferable consultation fee.

Informed Consent

Your condition and treatment options will be discussed so that you are appropriately informed and, together with your physiotherapist, can make decisions relating to your treatment. You are entitled to refuse any form of treatment and are encouraged to communicate any concerns with your physiotherapist. Consent can we withdrawal by patient at any time.

Personal Questions Matrix Healthcare respects privacy and dignity of every individual. You have full control over what and how you would like to disclose any personal matter. In order to obtain a clear picture of you injury and impact on activities of daily living or function, your physiotherapist may ask questions of a personal nature. The more relevant information you provide gives your physiotherapist details to create a specific and effective treatment plan for your requirements. Our staff adheres to the privacy and confidentiality act, but also understands the trusting relationship that is required for such disclosure of your personal information, and endeavor to treat this material with the upmost respect.

Physical Contact Matrix Healthcare respects personal choice. Physical therapy involves hands on assessment and treatment. It is likely that physical contact will be necessary during the course of examination, assessment and treatment. Again, you may withdraw your consent at any time and any physical contact will cease immediately. Please inform your physiotherapist if anything can be done to assist your comfort or if you have any concerns.

Children and Minors For the treatment of a minor this form must be signed by a custodian. Presence of a parent or caregiver is requested for anyone under the age of 16 years receiving treatment.

Treatment Risks Foreseeable risks will be discussed with you prior to administering treatment. It is patient’s responsibility to get clarified and be educated for the interventions. Patient understands the benefit and risk associated with physical therapy interventions and taking sole accountability for the outcome. Again, you may withdraw your consent at any time or request further treatment options.