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.

 

I understand that I am liable to pay for:

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• Any private treatment or copayment charges for ACC treatments.

• If I fail to attend my appointment or cancel without reasonable notice I may be charged a fee of $40.00.

• If I fail to pay for my appointment at the time of treatment I may be charged an account administration fee.

• Any treatment that is declined by ACC or other funder.

• The costs of materials such as orthotics, materials, products etc.

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.

           

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

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I consent to a discharge/update report being sent to my doctor or Medical Centre.

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Exclusion from Treatment
 

SCOPE OF POLICY: All staff of The Johnsonville Physiotherapy Centre.
 

POLICY: Any patient that is deemed unsafe due to illness or behaviour will be advised that they are unable to be treated that day.
 

PURPOSE: To ensure that The Johnsonville Physiotherapy Centre maintains the Health and Safety of all its employees and other clients.
 

PROCEDURE:
1. Any client that presents for treatment with an infectious/contagious illness may be advised that they are unable to be treated at that time. Another appointment will be arranged for a later date.
 

2. Any client presenting for treatment who shows signs of being under the influence of alcohol or drugs will be advised that it is unsafe to treat them at this point. They will be advised that they can rebook for treatment when they are no longer affected.
 

3. Any Patient presenting for treatment who is aggressive or abusive will be removed from the clinic and advised they cannot be treated. Police will also be informed.

 

I DECLARE – The information I have given about this claim is true and correct and that I have not withheld any information.

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I AUTHORISE – The treatment provider to lodge the claim for me.  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 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 accident.