new patient form - West End Osteopathic Clinic

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WEST END OSTEOPATHIC CLINIC PATIENT DETAILS
NAME:
DATE:
Date of Birth:
ADDRESS:
EMAIL ADDRESS:
PHONE
H:
W:
EMERGENCY CONTACT
M:
Name:
Phone:
OCCUPATION:
SPORTS, HOBBIES, INTERESTS:
MAIN AREA OF COMPLAINT TODAY: (eg. Neck / Back )
SECONDARY AREA OF COMPLAINT TODAY:
Please tick preferred REMINDER method:
HOW DID YOU HEAR
ABOUT US?
Phone call
Referred by existing patient
SMS
Email
Other (please specify):
Name:
Would you like to receive our monthly newsletter via email?
YES
NO
For the purposes of research, the West End Osteopathic Clinic may use de-identified patient data.
If you do not wish your de-identified data to be used in this way please check this box
As a matter of professional courtesy we may inform your regular GP or therapist that you have attended the
clinic for an Osteopathic consult. If you are happy for us to do this please fill in the details below.
General Practitioner / Regular Therapist:
Address:
Do you give permission for this Clinic to advise the above practitioner of Osteopathic treatment being
undertaken?
Yes / No
ARE YOU TAKING ANY MEDICATIONS?
Type/Name
________________________________
_______________________________
_______________________________
_______________________________
Reason for taking
_________________________
_________________________
_________________________
_________________________
APPOINTMENTS MISSED OR CANCELLED WITH LESS THAN 4 HOURS NOTICE MAY BE CHARGED. PLEASE UNDERSTAND
THAT BY NOT ADVISING US THAT YOU CANNOT ATTEND MEANS THAT SOMEONE ELSE WHO NEEDS TREATMENT MAY
NOT BE ABLE TO HAVE IT.
INFORMED CONSENT TO OSTEOPATHIC CARE
When performed by a qualified and Government registered Osteopath, osteopathic treatment is an
effective and safe method of care for many conditions. However, you must be informed that there
are risks associated with any treatment. Please read the following carefully:
1.
I will have the opportunity to discuss the proposed care with my practitioner, including
the nature, extent and purpose of such treatment.
2.
I understand that results are not guaranteed.
3.
I understand, and will have the opportunity to discuss with my practitioner, the
possible risks associated with my proposed care. These include, but are not limited to,
bruising or redness in the areas being treated, muscle and joint soreness, and an
aggravation of symptoms. There are additional potential risks associated with
manipulation (commonly known as the “cracking” technique) which range from
muscle and joint sprains/strains, nausea and dizziness, fractures, disc injuries, nerve
injuries and strokes (or like episodes).
4.
I do not expect my practitioner to be able to anticipate all potential risks and
complications associated with the proposed care. I wish to rely on the practitioner to
use their judgement during the course of treatment, which they believe is in my best
interests based upon the facts known at the time. Care is taken by all practitioners to
ensure that a successful treatment outcome is reached whilst minimising exposure to
the above risks.
5.
I hereby acknowledge my consent to the performance of the proposed osteopathic
care by my practitioner, and/or any other osteopath working is this clinic.
6.
I have read the above, and will also have the opportunity to ask questions about its
content.
I intend this consent form to cover the entire course of treatment for my present condition, and for
any other future condition(s) for which I seek treatment. I understand that I can withdraw my
consent at any time.
Practitioner
Patient Name
Practitioner Signature
Date:
Date:
APPOINTMENTS MISSED OR CANCELLED WITH LESS THAN 4 HOURS NOTICE MAY BE CHARGED. PLEASE UNDERSTAND
THAT BY NOT ADVISING US THAT YOU CANNOT ATTEND MEANS THAT SOMEONE ELSE WHO NEEDS TREATMENT MAY
NOT BE ABLE TO HAVE IT.
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