Workers Compensation

Patient Information Form

Please fill in all details currently available to you. Please remember to bring your doctors referral and/or current medical certificate

First Treatment Date

Title*

Given Names*

Surname*

Telephone*

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Next of Kin

Name

Phone

Injury type

Workers Compensation

Yes
No

Motor Vehicle Accident

Yes
No

Employment Details

Occupation

Employer*

Industry

Contact Name*

Phone Number*

Address

Postcode

Date of Accident*

Claim details

Have you lodged a Claim?

Yes
No

Claim Number

Insurance Company

Status of Claim

Case Officer

Referring Doctor’s Name

Address

Phone Number

Date of Referral

Injury Details

Brief description of problem*

Existing Health problems

Do you have an implanted cardiac pacemaker or any other device?

Yes
No

Do you have any metal implants?

Yes
No

Have you had any of the following health problems?

Other*

Consent*

I agree

Please read and agree to the declaration on this form

Authority to Release Information

I hereby authorize any professional Staff member of Cannington Physiotherapy to divulge to my employer and/or my employer’s insurer, information in relation to my workers compensation or motor vehicle accident claim which he/she may have acquired with regard to myself.

Acceptance of Responsibility for Payment of Account

I acknowledge that in the event of any worker’s compensation or motor vehicle accident claim being denied, I am ultimately responsible for the payment of all outstanding invoices. If payment is not received, administration and debt collection charges, in addition to any outstanding monies owed may be incurred.

WARNINGS

Please read the following information and indicate you understand these warnings by submitting the form below.

Heat Treatment:

When receiving a heat treatment, all you should feel is a mild comfortable warmth. If you feel any more than this, or if the heat concentrates in any particular spot, you must call your Physiotherapist immediately, otherwise you may be in danger of being burned.

Electrical Stimulation:

When receiving an electrical stimulation, any concentration of the current, or discomfort or pain must be reported immediately to your Physiotherapist. Otherwise, you may be in danger of sustaining an abnormal skin reaction. This may result in skin and tissue damage.

Acupuncture

Acupuncture treatment is a form of therapy in which fine needles are inserted into specific body points.
Acupuncture is generally safe with serious side effects less than one per 10,000 treatments. Common side effects include drowsiness, minor bleeding (3%), pain during treatment (1%), increased pain after treatment (3%) and fainting. If acupuncture is provided to your trunk there is a risk of a pneumothorax and your physiotherapist will seek your consent before this treatment is provided.

Skin reactions to massage oils, strapping tapes or acupuncture needles are a possibility.

By clicking submit you indicate you understand and agree to all the above information.

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