NEW CLIENT INTAKE FORM Physiotherapy and Occupational Therapy

Need help with this form or don't want to do online? No problem! You can fill in at one of our clinics we are at (if they don't have for any reason ask them to contact us please), we can also mail/fax or send to someone else for you to do! Simply call us (or ask someone else to) 1300 574 462 or email privatepractice@aachealthgroup.com.au and we can organise!

Thank you though for completing this form one way or the other! We know forms can be annoying, and you may have done many in the past! We want to get you to your therapist ASAP too, so we appreciate you completing to help your therapist have the best information to help your treatment. This form also gives you the information about our fees, your rights and meets our legal and insurance needs as well that are required for us to have a completed form before we can see you. Thank you! AAC Admin team and therapists

General Information

Client first name *

Client surname *

Date of birth *

Email Address *

Main Contact Number *

Secondary Contact Number

Home address *

Other? Please let us know so we may thank them

Are you filling out this form on someone else's behalf? (if so pls complete details below otherwise leave blank) *

YesNo

First Name

Last Name

Phone Number

What is your relationship to the client?

Emergency Contact Information

Emergency contact *

Phone *

Emergency contact’s relationship to you *

Health Information (VOLUNTARY -to help our therapist help you - you can discuss with them on the day if you prefer. If you or referrer have already sent do not need to complete)

What would you like to see an AAC Physio or OT for help with? What can't you do right now that you would like to be able to? What would make a great treatment outcome for you ?

Have you seen a medical doctor in the past for these conditions?

YesNo

(OPTIONAL) I consent to AAC Health Group contacting my medical practitioner or medical specialist.

Usual medical practitioner

Phone Number

Medical Practitioner Clinic Address

Medical Practitioner Email Address

(OPTIONAL) Please list any relevent medications you are currently taking you would like your Physio/OT to know

Medications

Dose

OPTIONAL (If relevent) Please list any allergies

Allergy

Severity

Optional - Please list any recent surgeries you would like your therapist to know about to help you at your treatment

Surgery

Date

Do you smoke? (optional)

NoYesI used to smoke

Do you use recreational drugs? (optional)

NoI have previously usedI currently use

Funding Information (how you or an organisation pay for your treatment)

Do you identify as financially disadvantaged ? (optional question - if you do and your referrer confirms this, we may be able to apply a discounted session with a maximum of $10 out of pocket expense subject to availability)

Do you identify as Aboriginal or Torres Strait Islander (this is voluntary to answer, and helps us understand cultural and health needs specific to our First Nations Australians)

If you have a Medicare Care plan - Medicare Card Number

Individual Reference Number

Expiry Date

If you are a veteran - pls enter DVA Card Number

Card Type

Expiry Date

If you have NDIS - your NDIS Number

Plan Start Date

Plan End Date

If NDIS who manages your plan?

If you are NDIS plan managed, or have a case officer for another funding type please let us know their details here

If you have a Workers Compensation/Insurance claim please enter your claim number here

Current fees (subject to change)

Standard 20 minute Medicare Chronic Disease Management/Team Care sessions in clinic or telehealth on referral from GP do not have a gap fee ($58 fee is fully rebatable by Medicare)

if you would like a longer consultation there is a gap fee. A 30 min session has a $25 gap fee (total cost $83 of which $58 is rebatable by Medicare) and a 40 minute session has a $49 gap (total cost $107 of which $58 is rebatatable)

Private sessions in clinic or telehealth (including private health funds)- 20 minutes cost $65, 30 minutes $90, 40 minutes $107. Private health rebates may apply if you have extras, pls check with your fund prior to attending.

Private home visits, pool/gym or a clinic/location we do not normally visit including aged care facilities- Contact us for quote

DVA - A current gold/white card is accepted as payment upon GP referral

Workcover in clinic or offsite pool/gym/home - A current accepted claim with GP referral in place is accepted as payment. It is your responsibility to maintain this claim and referral otherwise you are liable for all charges personally

NDIS, Home Care packages/CHSP (Commonwealth Home Support Program) and STRC (short term restorative care program) are $0 out of pocket as long as service is approved and funds available in plan.

Not funded above/unable to afford allied health ? Don't let it stop you having the therapy you need! There is help available, please let us know if you need assistance with any of the below options

If you are over 65 - you may be eligible for assistance including funding for allied health via a Home Care package, Commonwealth Home Support Program or Short Term restorative care - you or we or your referrer can help with a referral via My aged care www.myagedcare.gov.au

If you are under 65 and have a long term disability you may be eligible for assistance including financially for allied health through the NDIS - see www.ndis.gov.au for further details and we can assist with applications.

For financially disadvantaged clients confirmed by a referrer (GP or organisation) as part of AACs committment that everyone should have access to allied health we have agreed to apply a discount to maximum out of pocket expense (if applied) is $10

Consent

I agree to the following terms and conditions, and will discuss with AAC Health Group Australia if I am unsure of any of the following information. If I am signing on behalf of someone else I have the medical and legal authority to do so, have provided complete information and have consulted with the person I am signing for to make decisions and explain treatment and this form.

AAC Health Group Australia are bound by privacy rules to protect my privacy and medical information including storage of my information, and we will not release to others unless with your permission or via order from an appropriate government body. I can request my medical information at any time by contacting AAC. I have read and agree to AAC Health Group's Privacy Policy (please contact us if you cannot view this form and we will give you a copy)

I understand undertaking treatment and exercise that I have been told that it is highly recommended I discuss with my treating doctor before I undertake treatment to confirm that I am safe to do so. I will alert AAC Health Group Australia and my practioner if my medical condition changes.

I understand that any treatment may come with some risks such as mild muscle soreness if I undertake new movements. Your therapist should explain these risks, and I will check with my therapist and have them explain if I am unsure of the risk.

I consent to my treatment if the therapist feels is clinically appropriate to being conducted via telehealth (telephone or online meeting ie Zoom, we assist with technology and setup if you need). I understand I can withdraw my consent for this at any time.

I resolve to alert AAC Health group Australia if I have an adverse reaction, or am unhappy with any element of my treatment, billing, communication with any AAC employee or someone who works with AAC by calling 1300 574 462 ASAP or privatepractice@aachealthgroup.com so we can help.

For all cancellations less than 2 Business Days for any reason we have a cancellation policy where we will charge 100% of the consultation charge (which you may need to pay personally if not funded by another method)

I confirm that above information I have provided is true, complete and accurate and I agree to pay a cancellation fee as outlined above. *

Date *

Signature *

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