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Rehab Physio Centre - Consent Form
PLEASE ENSURE YOU HAVE AN APPOINTMENT BOOKED BEFORE COMPLETING THIS CONSENT FORM.
Please complete the below consent form before attending your appointment.
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Email
*
Your email
Have we treated you at Rehab Physio Centre before?
*
Yes
No
Title
*
Mrs
Mr
Ms
Dr
Miss
Master
Other:
First Name
*
Your answer
Middle Name/s
Your answer
Surname
*
(please type in CAPITALS)
Your answer
Known as
(if different from above)
Your answer
Date of birth
*
Your answer
What is your ethnic background?
*
(this information is collected for statistical reasons only, to help ACC develop services that are culturally appropriate)
NZ European
Other European
NZ Maori
Cook Island Maori
Tongan
Niuean
Fijian
Other Pacific
South East Asian
Indian
Other Asian
Chinese
Samoan
Tokelauan
I'd prefer not to say
Other:
Required
Home address
*
(please include: street address, suburb, CITY/TOWN and post code)
eg. 27 Linton St, Central, Palmerston North 4410
Your answer
Mobile/Primary phone number
*
Your answer
Home phone number
*
(select n/a if you do not have a landline)
N/A
Other:
Work phone number
*
(select n/a if you do not have a work phone number)
N/A
Other:
Emergency contact
*
Your answer
Emergency contact phone number
*
Your answer
NHI (National Health Index) number
This is not a necessity, but if known, this would be very helpful with accessing existing ACC claim details
Your answer
Occupation
*
Your answer
Current Doctor
*
Your answer
Doctor's Practice name or location
*
Your answer
Are you a Southern Cross member?
(If so, please include your membership number in 'other' as we can invoice Southern Cross directly on your behalf if your policy covers physiotherapy)
No
Other:
Clear selection
Are you affiliated with a sports club?
(If so, please type the club's name below)
Your answer
Why did you choose Rehab Physio Centre?
*
Referred by Doctor (if so, please specify who in 'other')
Referred by Specialist (if so, please specify who in 'other')
Referred by Surgeon (if so, please specify who in 'other')
Been here before
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Employer referred
Self-referred
ACC
Friend/family recommended
Other:
Required
Do you have any cultural needs to be considered when planning your care?
*
(if yes, please specify what you require in 'other' or, if you prefer to discuss this in person you may do so with your physio at your appointment)
Yes
No
Other:
Required
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