PATIENT INFORMATION RECORD

Personal Details
Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Referral Details
Referred by
Referred by
The person who referred you
Treating Specialist
Treating Specialist
Treating Specialist (if other than referrer)
GP
GP
GP (if other than referrer)
Next of Kin / Emergency Contact Details
Next of Kin / Emergency Contact
Next of Kin / Emergency Contact
Emercency contact's relationship to you
Payment Method
Payment Method *
Please select how you will be paying for your appointment
Your claim number will be send via text and/or email shortly after lodgement of your claim
Workcover Case Manager
Workcover Case Manager
I have read and accepted the Privacy Act and Consent Form (below) *
Date of Acceptance *
Date of Acceptance

PRIVACY ACT
CONSENT FORM

I. The purpose of this form is to ask for your written consent to the:
A. collection;
B. use; and
C. disclosure,
of your personal (including health and sensitive) information.

II. We ask that you provide the information so as to enable us to properly and effectively assess and treat your medical condition in this and future episodes of care. We will keep your information confidential. The only people who have access to the information are those employed in this practice.

III. We specifically ask for your consent to make available your personal information to other clinicians who are providing clinical services to you in respect of your medical condition. Disclosure of your personal information to other clinicians may occur through our referring you to other clinicians or providers of health care or like services, or for tests, or other forms of communication with your referring practitioner, general practitioner or any other health care provider.

IV. Further, we specifically seek consent to use and disclose your personal information for secondary purposes if those purposes directly relate to your ongoing care or your failure to attend for ongoing care.

V. In addition, as our practice is actively involved in teaching programs, we ask that you consent to the use of some of your personal information in an unidentifiable form. The information we ask to use may include your age, range of motion of various joints, grip strength, clinical photos and information about your clinical outcomes. We will ensure that this information is not identifiable as your personal information.

VI. In certain circumstances, some of your personal information together with a copy of any invoices we may have rendered to you or others, may be forwarded to third parties if it is necessary for us to take steps to recover our fees. The information that we would provide to third parties in such circumstances would include your name, address, contact details, and account details (eg. dates of service, service provided and account amount). By signing this form, you agree that accounts not settled by a third party becomes your responsibility and you agree to cover any further costs incurred should it be necessary to forward on any outstanding accounts to a collection agency.

VII. Finally, we advise that unless we are in receipt of an additional Consent Form signed by you, no information whatsoever will be released to any third party, such as your employer, solicitor or insurance company, unless it is required by law. If however, you have attended today for an assessment for a medico/legal report, your signature is evidence of your consent to collect, use and disclose your personal information for that purpose. You are not obliged to provide the information requested. Your signature below is your consent to its collection, use and disclosure by HandsOn as set out in this form.

VIII. If you have ANY medical conditions (such as a pace maker) please disclose them to the therapist as these medical conditions can alter the intensity of treatment.