New Patient

Patient Registration Form

Please complete this form before your first appointment. It takes about 5 minutes and helps us make the most of your consultation time.

Registration

Consent Form

All Done

Personal Details

Fields marked * are required.

First Name *

Last Name *

Date of Birth *

Gender

Ethnicity

Phone Number *

Email Address *

Residential Address

Occupation

Referred by (if applicable)

Emergency Contact

Full Name *

Relationship to You *

Phone Number *

ACC Claim Details

ACC covers the cost of treatment for injuries caused by an accident. If you have an existing ACC45 claim, enter your claim number below. If you don't have one yet, tick the box and we'll help you lodge it at your first appointment.

Are you booking for an ACC-funded appointment? *

Yes — I have an ACC45 claim number Yes — but I don't have an ACC45 claim number yet No — this is a private (non-ACC) appointment

ACC45 Claim Number (leave blank if you don't have one yet)

Date of Injury (if applicable)

Reason for Your Visit

What brings you in today? *

Body area affected *

How long have you had this problem?

Pain level right now (0 = none, 10 = worst imaginable)

Have you seen anyone else for this?

What are your goals from physiotherapy?

Medical History

Do you have any of the following? (Select all that apply)

Diabetes Heart condition or cardiovascular disease High blood pressure Osteoporosis or bone density issues Current or recent cancer diagnosis Bleeding disorder or anticoagulant therapy Neurological condition (e.g. stroke, multiple sclerosis) Mental health condition affecting treatment Currently pregnant or postpartum (within 12 months)

Any previous surgeries or significant injuries relevant to your current problem?

Any other medical conditions we should know about?

Medications & Allergies

Current medications (include dosage if known)

You don't need to list every supplement, but please include anything that affects pain, blood thinning, bone health, or inflammation.

Do you have any known allergies?

Yes No

If yes, please describe your allergies

Any specific concerns about treatment (e.g. needles, certain manual therapy techniques)?

Consent

AI-Assisted Clinical Notes (Heidi)

We use Heidi, an AI clinical documentation tool, to record and summarise consultations. Audio is processed by Heidi Health (Australia) to generate clinical notes and is not stored long-term or shared with third parties. You can opt out at any time — just tell us before your session and your physio will take manual notes instead.

Yes — I consent to Heidi being used to generate my clinical notes. No — I prefer my physiotherapist to take manual notes. (No audio will be recorded.)

Full Name (as signature) *

Date *

If this form is being completed on behalf of a patient under 16, please provide the name and signature of their parent or legal guardian.

Your information is transmitted securely and stored in accordance with our Privacy Policy.