3 Sydney Ave Geelong Vic 3220
[email protected]
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Phone (03) 5221 7171
Home
About
About us
What is hand therapy?
Our staff
Services
Custom made compression garments
Custom made splints
Hand therapy
Hand therapy at home
Inpatient visits
Pain Management
Post operative rehabilitation
Return to work plans
Scar management
Waterproof fibreglass casting
Conditions
Burns and Scars
Carpal Tunnel Syndrome / Release
DeQuervain’s Tenosynovitis
Dupuytren’s
Fractures and Dislocations
Mallet Finger
Osteoarthritis
Rheumatoid Arthritis
Repetitive Strain Injuries
Sporting Injuries
Tendonitis
Tennis Elbow
Thumb Pain
Trigger Finger
Workplace Injuries
Wrist Pain
FAQs
Contact
Contact us
New Patient Registration
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News!
Appointments available at Lara Physio from July 19th. Mondays 9am to 1pm.
New Patient Registration
New Patient Registration
Your details
Title
*
First name
*
Surname
*
Preferred name (if different from above)
Date of birth (DD/MM/YYYY)
Home phone
Work phone
Mobile phone
Email
Address
Suburb
Occupation
Presenting problem:
*
If you have had investigations, Where were they taken? (N/A for none)
Lake Imaging
BMI
Radius
Epworth Imaging
RIS
TLC Imaging
Other
Other
N/A
Date of injury
Date of surgery (if applicable)
Name of surgeon (if applicable)
Referring doctor
Regular GP and/or GP clinic (N/A if none)
*
*NB - We use this to keep your GP up to date! (GP's appreciate our feedback and like to be kept up to date with their patients)
Parent or guardian details (if applicable)
Parent or guardian name
Home phone
Mobile phone
Work phone
Email
Are you a pension/concession card holder?
*
Yes
No
Which account type will you be paying with today?
*
Workcover
TAC
DVA
EPC Plan
Private
Other
Other
Medicare details
*
Workcover details
Workcover Claim Number
Insurer
Employer
*
Employer Contact Person
Employer Phone
*
Employer Email
TAC details
TAC Claim Number
Date of Injury
*
DVA Card
*
Gold Card
White Card
DVA Number
*
How will you be paying today?
*
Cash
Cheque
Credit Card
EFTPOS
Other
Other
Details of person responsible for payment of our invoices
As above
Different person
Name
Address
Address
Address line 1
Address line 1
Address line 2
Address line 2
City
City
State
State
Post code
Post code
Phone
Private Health Fund (if applicable)
Membership number
Ref
Are you allergic to:
*
Tapes
Massage creams*
Other (please specify)
Other (please specify)
No Allergies
*The main ingredients of the massage cream we use are: Arnica montana, Hypericum perforatum (St John’s Wort) Calendula officinalis and Melaleuca alternifolia (Tea Tree Oil)
Do you have a pacemaker?
*
Yes
No
Do you have a history of fainting?
*
Yes
No
Do you have any other health concerns you would like your therapist to know about?
Please discuss any concerns with your therapist before commencing treatment.
Checkboxes
*
I understand the above terms and conditions and consent for my/my child's therapist to access and view any images i.e X-rays, ultrasound, MRI investigations related to my/my child's injury or condition, and to discuss my/my child's treatment with my/my child's referring GP or Surgeon
Name
Date
Signature
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