Physiotherapy Informed Consent Form

Name :

Medical Conditions (Please Circle): Do You Have Or Ever Had…
Joint Surgery (replacements, reconstructions, tendon repairs or arthroscopy) Yes No Heart Conditions ( e.g. angina arrhythmias, murmurs, surgery or heart attack) Yes No
Spinal Injuries or Surgery Yes No Stroke Yes No
Diabetes Yes No Cancer Yes No
Bowel/Bladder Abnormalities Yes No Osteoporosis Yes No
Kidney Problems Yes No Epilepsy/Seizures Yes No
Are you, or do you have reason to believe, you may be pregnant Yes No Bleeding Disorders Yes No
High Blood Pressure Yes No Dizziness or Blackouts Yes No
Osteoarthritis or Rheumatoid Arthritis Yes No Metal Implants Yes No
Other Yes No
Do you have or have you experienced any medical condition which you believe may impact on your ability to safely participate in an assessment program involving repetitive movement, manual handling and/or vigorous exercise? Yes No
If ‘yes’ please provide details:
Do you have or have ever had conditions affecting your; bones, muscles or joints which impacted on your ability to carry out normal activities, required time off work, required treatment, awaiting surgery or is ongoing or recurrent in nature? Yes No
If ‘yes’ please provide details:
Please list any medication you are currently taking (including non-prescription medication):

Physiotherapy Informed Consent Form

Please read the following carefully:

  • If you have any medical conditions/health concerns you believe will affect the success of your treatment, inform the physiotherapist as soon as possible.
  • I have completed the questionnaire correctly and honestly to the best of my knowledge.
  • I understand that I will be given the opportunity to discuss any concerns I may have during the program and prior to commencing the sessions.
  • I clearly understand that any possible risks will be highlighted and that I am responsible for making the health professional aware of any reason (health or previous injury) that may place me at risk.
  • I voluntarily agree to participate in the program and understand that my participation may be terminated at any point for health or injury reasons.
  • I am aware that I am required to give my Physiotherapist at least 24 HOURS notice if I am unable to attend an appointment (exceptional circumstances will be considered) This may have the following effects:
  • The Missed Appointment may absorb part of your entitlement to Physiotherapy under your Compensation claim
  • The Insurer may recover the cost of the missed appointment directly from you
  • Please complete the following if this relates to a Workers Compensation claim:
    Employer (who pays your wages): _________________________
  • In the event my workers compensation claim is denied by the insurance company, I accept responsibility for the physiotherapy charge

I consent to an authorised Guardian Occupational Physio Treating Physiotherapist; my employer, other treating practitioners, legal representatives and rehabilitation providers to exchange information for the purposes of managing my injury as detailed above and with any insurer involved in any subsequent claim.

Signature: _________________________

Date: _________________________

Choice Of Rehabilitation Provider

GERehab Pty Ltd is the parent Company of

  • Guardian Occupational Physio
  • Guardian Exercise Rehabilitation
  • Guardian Workplace Rehab

Meaning they are all owned by the one Organisation. You have the right to choose who your provider is across any services within Workers’ Compensation.

Should you be undertaking one of the above services and it is deemed medically appropriate that you engage another of the services listed above, you have the right to choose the same type of service with a different provider.

I have read and understood that I always have a choice of provider with any treatment under Work Cover.

Signature: _________________________

Date: _________________________