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Exercise PhysiologyDietetics

Do you suffer from OR have any of the following: (please tick).

MigrainesHeadachesDizzinessNumbnessJoint ReplacementChronic FatigueEpilepsyCancerMultiple SclerosisHeart ConditionsStrokeVaricose Veins/Blood ClotsDiabetesAsthmaPregnancy

Note: by providing your email address you give permission to receive the occasional communication from us regarding your treatment or special offers we may have. All information recorded is private and confidential.

As part of our duty of care to you that all physicians, physiotherapists and other allied health practitioners inform you of any material (pertinent) risks associated with professional treatment techniques.

Some therapy techniques such as therapeutic massage, joint manipulations (low amplitude, high velocity), traction or mobilisations (low amplitude, low velocity) have a very slight risk of causing injury. A remote possibility of injury to structures such as but not limited to; nerves, bones, muscles, ligaments, discs or arteries exists. Research evidence indicates that skilled cervical (neck) manipulation is safer than taking anti-inflammatory medication. In very rare circumstances (less than 1 in 163,000 to 5.8 million), damage may occur to the vertebral arteries in the neck and the patient may suffer a stroke. There is a small risk that treatment may produce pressure on nerves going down the arm or leg.

Electro-physical agents such as ultrasound, laser or TENS therapy have been linked to minor burns and abnormal skin reactions. Acupuncture and the above listed techniques can occasionally cause temporary local swelling, bruising or transitory increases in the levels or distribution of pain or other symptoms such as dizziness. In very rare cases acupuncture has been reported as being associated with bodily infections or collapse of a lung (less than 1 in 70,000 - 1.27 million). Allergic skin reactions to massage oils, strapping tapes, acupuncture needles or topical applications are a possibility.

Following a verbal explanation of the examination results and the therapeutic techniques the therapist deems suitable for your present condition, you will be asked to give your consent to treatment. You have the right to decline treatment that the therapist offers at any time. You have the right to a second opinion at any time.

I will endeavour to provide accurate and thorough information to the therapist to the best of my ability in regards to my health condition. I give permission to the therapist to exchange relevant confidential information with my doctor and other medical specialists when necessary. This will remain confidential.

Allied Family Physiotherapy Pty Ltd (AFP) is committed to managing and protecting the privacy and confidentiality of your personal information. AFP is subject to the Privacy Act 1988 (Cth) (Privacy Act) and will adhere to the Australian Privacy Principles when collecting, using, disclosing, securing, correcting, updating and providing access to personal information. As part of its commitment to privacy, AFP has adopted a Privacy Policy which sets out how it will deal with the management of personal information. A full copy of AFP’s Privacy Policy is available at your request.

In conjunction with the AFP Privacy Policy, the following applies to any information that you provide to AFP:

1. you authorise AFP to collect, use, store, correct, update, disclose or otherwise process any information including personal information which relates to and/or identifies you, including but not limited to, your name, address, date of birth, employment details, contact details, emergency contact details, Medicare Australia Card information, Department of Veteran Affairs entitlement information, health insurance information, medical history and other information regarding your health and lifestyle decisions (Personal Information), to the extent reasonably necessary for AFP to provide the services you requested from AFP (and/or its contractors, employees, directors, officers, affiliates, subsidiaries, related parties, agents, successors and assigns) or third parties and also for the purpose of researching, developing and enhancing AFP ‘s services and/or complying with AFP’s legal obligations;
2. you acknowledge and agree that the types of Personal Information which AFP collects will depend on the circumstances of its collection and the nature of your particular dealing with AFP and you further acknowledge and agree that AFP is required to collect certain Personal Information to ensure compliance with its legal obligations or as required by various government agencies (such as the Department of Veteran Affairs and Medicare Australia) or as required by various regulatory bodies (such as Exercise & Sports Science Australia);
3. you acknowledge and agree that in some circumstances, Personal Information is provided to AFP by third parties or other organisations conducting activities on your behalf. Such third parties would include for example your medical practitioner or Medicare Australia and it is assumed that you have provided consent for your personal information to be used and disclosed to AFP this way;
4. you acknowledge that Personal information AFP has collected from you (including but not limited to the information contained in the above Pre-Exercise Screening Questionnaire) may be transferred to AFP’s contractors, employees, directors, officers, affiliates, subsidiaries, related parties, agents, successors and assigns or third parties where AFP considers it is necessary to meet the purpose for which you have submitted the Personal Information and you therefore authorise AFP to disclose your Personal Information to any such parties to the extent necessary to perform the services to you or as otherwise required by law or with your consent;
5. you acknowledge and agree that AFP uses the Personal Information which you provide to AFP to deliver services most suited to your needs. AFP will not use your Personal Information for purposes other than those set out in the AFP Privacy Policy without your consent or unless that use is authorised under the Privacy Act;
6. you acknowledge and agree that AFP stores Personal Information in paper based and other hard copy documents at physical office locations where services are provided, at its registered office and at off site storage facilities, in electronic records and on its online practice and patient management software (currently Halaxy). The management of your Personal Information through any online practice and patient management software is not governed by AFP’s Privacy Policy but rather, is governed by the privacy policy and terms of use of that software provider.
7. by completing the above Pre-Exercise Screening Questionnaire and providing any Personal Information to AFP at any time, you consent to AFP collecting, using, storing, correcting, updating, disclosing or otherwise processing your Personal Information on the above terms and in accordance with AFP’s Privacy Policy. If you would like to access, review or modify any part of your Personal Information at any time then you should contact AFP.

By completing the above Informed Consent form and signing below, you acknowledge and agree:

1. that Allied Family Physiotherapy (AFP) does not accept responsibility for lost, stolen or damaged valuables, cash or personal items;
2. to abide by the rules of and follow any directives of AFP and any facility where AFP provides its services to you (Facility) at all times;
3. that you have voluntarily engaged the services of AFP and you are making use of the services AFP provides and accessing and using the Facility of your own free will;
4. that you have provided all relevant information regarding your medical history and the current status of your health and any current medical conditions to AFP;
5. that all information that you have provided to AFP is complete and accurate to the best of your knowledge;
6. that, if relevant, this Informed Consent form (including this Disclaimer) extends to any hydrotherapy services provided to you by AFP and any reference to ‘Facility’ includes any pool from which AFP provides its hydrotherapy services to you;
7. that, if you have provided your credit card details to AFP, you authorise AFP to input those details into its online practice and patient management software (currently Halaxy) on the basis those details will then be stored electronically by its online practice and patient management software to pay future invoices issued to you by or on behalf of AFP for services provided to you and in doing so, you authorise the payment of such invoices using those details, you acknowledge and agree that AFP simply inputs the details into its practice and patient management software and that it is not responsible or liable for the storage, processing or transmitting of such details and you accept the Payment Processing Terms of AFP’s practice and patient management software which are available to view at https://halaxy.com/article/terms;
8. that the services that AFP provides and your access to and use of the Facility involve a degree of risk, including physical and non-physical harm to yourself, and that you have voluntarily chosen to participate in the services that AFP provides and access and use the Facility, accepting that the materialisation of such risks may cause personal injury, death or property damage;
9. that exercise or physical activity is physically demanding and may pose a risk to your health and you accept such risk;
10. that you forever release and discharge AFP (and all of its contractors, employees, directors, officers, affiliates, subsidiaries, related parties, agents, successors and assigns) and the Facility from any and all claims, actions, suits, demands, damages, interest and costs arising out of or as a consequence of any services provided by AFP or your access to and use of the Facility (Claims) for any loss, damage or injury to person (including yourself) or property whether caused by negligence, wilful act or omission, accident, another person or however otherwise caused; and
11. (xi) that you forever indemnify AFP (and all of its contractors, employees, directors, officers, affiliates, subsidiaries, related parties, agents, successors and assigns) and the Facility against all Claims for any loss, damage or injury to person (including yourself) or property whether caused by negligence, wilful act or omission, accident, another person or however otherwise caused.

I have read this form, understand the information it contains and give my consent to treatment.