Patient Consent - Warwick Physioworks

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👤 Patient Details

Full Name

Date of Birth

Phone

Address

📋 Additional Information

Emergency Contact

Referring Doctor / GP

Medical Conditions / Allergies

✅ Treatment Consent

By signing, I understand:

Treatment techniques like massage, joint manipulation, and dry needling carry minimal risks including temporary pain, swelling, or bruising
In rare cases, more serious complications may occur
I will inform my therapist of any allergies to creams, oils, tapes, or needles
I consent to treatment and understand I can decline at any time
I allow information sharing with other healthcare providers as needed
All information will remain confidential
I consent to email communication and marketing materials from Warwick Physioworks

I have read and understand the above treatment information

📅 Cancellation Policy

6+ hours notice required for cancellations/reschedules
Less than 6 hours notice or no-shows incur full appointment fee
Cancellation fees are not covered by Medicare, private health funds, DVA, or WorkCover

Cancel by: 📞 Phone: 4661 7756 | 💬 SMS: Reply "NO" to appointment reminder

I have read and agree to the cancellation policy

📝 Agreement

I confirm that the details I have provided are correct, I consent to treatment, and I consent to email communication and marketing materials from Warwick Physioworks.

✍️ Signature

Sign here with finger or stylus

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Consent Submitted

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