New Client Consent And Acc Information Form

ACC45 #: ________________ New / Existing

NEW

Client Consent and ACC Information Form

Injury: ____________________________________

College

Entered

E-Sent

:

SECTION 1 - PERSONAL INFORMATION (Please complete all sections)

FIRST NAME:

PREFERRED NAME:

(if different)

LAST NAME:

MALE

FEMALE

DATE OF BIRTH:

ETHNICITY:

CELLPHONE:

HOME PHONE:

WORK PHONE:

Emergency Contact Number and

Name

:

E-MAIL ADDRESS:

Parent/Caregiver:

Email addresses will only be used by us for sending of exercise programs, newsletters and surveys.

ADDRESS:

SUBURB:

POSTAL ADDRESS:

POST CODE:

EMPLOYER NAME POSTAL

OCCUPATION:

ADDRESS: *(IF WORK

WORK INTENSITY:

PLACE INJURY)

Light/Moderate/Heavy

NAME OF GP:

MEDICAL PRACTICE:

HOW DID YOU HEAR ABOUT US:

Previous Patient

GP

Specialist

Yellow pages

White pages

Local directory

FIT CLUB

Signage

Flier

Local paper

Sports team

College

Other (please specify)

WHAT MADE YOU CHOOSE US:

Previous Patient

Word of Mouth/Family/Friend

Location

Able to get appointment

First one I called

Price

GP/ Specialist Referred

Services offered

College

Other (please specify)

SECTION 2 - GENERAL HEALTH QUESTIONNAIRE:

Pregnant

Osteoporosis

Asthma/Respiratory/Hyperventilation

Circulation

HIV/Hep C

Cancer

Continence Issues

Hearing/sight impaired

OsteoArthritis

Allergy (Specify)

Stress/Anxiety

Physical disability

History of Falls

Heart/ Cardiovascular condition

Intellectual Disability

MEDICATIONS – PLEASE LIST:

SECTION 3 - ACC CLAIM INFORMATION (Do Not Complete if Private Patient)

DATE OF INJURY:

SCENE/SITE:

Work

e.g. Home, *

, Sport, School, Vehicle

TIME OF INJURY:

LOCATION:

(approx)

e.g. Tauranga, Auckland

Circle

Body Part

Read Code:

DESCRIPTION OF HOW INJURY OCCURED:

L

R

SECTION 4 - 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.

AGREEMENT TO PAY:

I understand that I am liable to pay for :

Treatment if it is not covered by ACC

•

Any KCP co-payment charges for my treatment, which is not covered by ACC.

•

Any treatment that is declined by ACC or other funder

•

The costs of materials such as collars, splints, tape etc

•

If I fail to attend or cancel my appointment within 4 hours I will be required to pay a non attendance fee (details at reception)

•

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.

rd

CONSENT TO RELEASE INFORMATION TO A 3

PARTY

I consent to the disclosure of my records to any person/organization necessary for the effective management of my condition.

I consent to a discharge/update report being sent to my doctor or medical centre.

ACC DECLARATION

I DECLARE: That the information I have given about this claim is true and correct and that I have not withheld any information likely to affect my application.

I AUTHORISE: 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 that 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 injury)

SIGNED: (If under 16 must be signed by parent/guardian & contact number)

DATED:

Office Use:

Tick

No.

Notes completed if

offsite