Consent To Treatment

    Your Details

    Why Choose Us:

    Please State

    Recommended By

    Health Questionnaire: Does any of the following apply to you?

    PregnantCardiovascular conditionHearing or sight disabilityHIV +. Hep CSkin InfectionIntellectual disabilityPhysical disabilityCancer (include previous)Other




    Have you already completed an ACC claim form for this injury?


    Have you had treatment with another Physiotherapy Clinic For This Injury


    Cause Of Injury

    Place Of Injury

    If work injury, please advice

    Work Intensity

    Is this injury as a result of a motor vehicle accident?


    Is this a work related gradual process, disease or infection claim?


    Consent To Treatment:

    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 consent to receive emails from this practice.

    Agreement To Pay:

    I understand that I am liable for payment:

    • Of a co-payment of $38 ($30 Concession) per consultation. At Campus Health ONE initial ACC appointment per year is free and follow-ups treatments are $28.

    • If any treatment is declined by ACC or other funder I am liable for the cost of a private appointment, $75 ($68 concession).

    • For the costs of materials such as collars, splints and taping.

    • For non-attendance or late cancellation of appointments. (a $25 fee will apply)

    I understand that in the event of this Practice engaging a Debt Recovery Service to recover your debt, you will be liable for any recovery fees.

    Consent To Release Information To A Third 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

    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)

    Outcome Measures

    Patient Specific Functional Scale:

    Please identify 3 activities that you are having difficulty with due to your injury, please mark a score out of 10 on your ability to complete them.

    • 0 is unable to complete the activity at all.

    • 10 is able to complete the activity at the same level as before you were injured.

    Numerical Pain Rating Scale:

    Please circle your pain level on a scale of 0-10. This is the average over the last 24 hours.

    Also circle with regards to your BEST and WORST pain level related to this injury – You should have circled three numbers

    What is the main thing you would like to achieve by the end of today’s session?

    What is your main goal that you want to achieve with physiotherapy treatment?