Physiotherapy Consent Form

Client Information
General Health Questionnaire

Please tick those that apply:

Have you recently taken or are taking:

ACC
If yes:

The information I have given about this claim is true and correct and that I have not withheld any information

The treatment provider to lodge the claim for me. The collection and release of any information about me to the extent that this is needed to prevent future injuries, determine cover and/or assess my entitlement to compensation, rehabilitation assistance, medical treatment and/or the appropriate level of care and personal attention I should receive. ACC to contact anyone who holds relevant information, including any external agencies or service providers (such as medical practitioners, specialists, New Zealand Police and Treatment Providers, IRD, WINZ, Assessment Agencies, employers and witnesses to the accident.

Consents

I hereby agree to consent to treatment by an appropriately qualified Physiotherapist for the purpose for providing comprehensive physiotherapy services as may be necessary in support of my illness, injury or condition. I have been given the opportunity to read clinic information prior to treatment. I understand I have the right to decline part or all of the treatment being offered. I understand my right to a second opinion.

  • I agree to consent to allowing the physiotherapist to contact me by phone for telehealth purposes,
  • I agree to consent to allow the physiotherapist to contact me by video link

I understand that I am liable to pay for :

  • Any private treatment or copayment charges for ACC treatments.
  • If I fail to attend my appointment or cancel without reasonable notice I may be charged a fee.
  • If I fail to pay for my appointment at the time of treatment I may be charged an account administration fee.
  • Any treatment that is declined by ACC or other funder.
  • The costs of materials such as orthotics, materials, products etc

I understand that if this service requires to engage a Debt Recovery Service to recover my debt, I will be liable for any recovery fees.

  • I consent to the disclosure of my records to any person/organisation necessary for the effective management of my condition.
  • I consent to a discharge/update report being sent to my doctor or medical centre.