Title MrMrsMsMissMastDr Surname Given Name Address Suburb Post Code Date of Birth Occupation Home Phone Work Phone Mobile Phone Fax No. Email Address Private Health Insurance (Fund Name Only) Pension Number DVA Number GP Name Do you have a pacemaker/metal implant or major Health Problem? YESNO If yes, please provide details Are you currently having radiation therapy (brachytherapy)? YESNO If yes, please provide details Emergency Contact Details: How did you hear about us? WEBSITEDR REFERRALWALK INWORD OF MOUTHOTHER If other, please provide details PATIENT TO PLEASE READ THE FOLLOWING: Heat Treatment: When receiving heat treatment, all you should feel is a mild comfortable warmth. If you feel any more than this you must notify the physiotherapist immediately as there is a possibility you may be burnt. Electrical Stimulation: When receiving electrical stimulation, any concentration of the current discomfort or pain must be reported immediately to the physiotherapist. Otherwise there is a possibility of sustaining an abnormal skin reaction or tissue damage. CONSENT FORM We require your consent to collect personal information about you. Please read the information below. By submitting this form you agree to these terms. I understand I have the right to request access to my information. I understand that I may withdraw my consent for this practice to use and disclose my personal information, except where legal obligation must be met. I understand that I am not obliged to provide any information requested of me, but my failuer to do so will compromise the quality of health care treatment given to me.