Consent & Registration Form


When you have completed this form, please remember to click the SUBMIT button at the bottom.

Personal Information

Title (Please select one)
First Name
Last Name
Date of Birth (DD/MM/YYYY)
Mobile Number
Landline Number(s)
Email Address
Home Address
Family Doctor
Medical Practice
Ethnicity
Occupation
Employer
Work Intensity (Please select one)
Please list any medical details that may affect your treatment
Where did you hear about us?
If you were referred to us, who referred you?
Please indicate if you have any ethnic, religious or language needs
If you answered YES, please tell us what special needs you have

Injury Information

Date of Injury DD/MM/YYYY
ACC number or workplace insurer contact (if applicable)*
Please describe what happened

Client Consent & Terms

*Please note that if you are unable to provide us with your already lodged ACC number or workplace insurance details - we may not be able to access this information for you due to privacy regulations.  We rely on you to provide us with this information, otherwise you will be charged privately for the appointments.  We can reimburse you once the information has been provided and cover is confirmed.

By signing this form I hereby give consent to undertake treatment by an appropriately qualified Physiotherapist or Occupational Therapist at Hand Rehab Ltd.  I understand I have the right to decline part or all of the treatment being offered.  I understand my right to a second opinion.  If under ACC terms I accept that I have to take personal responsibility for my rehabilitation and to actively participate in the treatment plan developed.

By signing this form I give consent for disclosure of my records if necessary for effective management of my condition and for an update report to be sent to my GP. If under ACC regulations I have already agreed to the disclosure of information to ACC necessary for entitlement of treatment.

By signing this form I understand that I am liable to pay for treatment declined by ACC or another funder.  If I fail to attend my appointment or cancel without sufficient notice of 12 hours I may be charged a fee of $40.  Any outstanding debts may be transferred to a third party.

By signing this form I declare this information to be true and correct and that I have not withheld any information.

Date (DD/MM/YYYY)

I agree that all the information I have supplied is accurate and that I have read and agree to the Client Consent & Terms above Yes

Client Signature (Please type name)

  Therapist Signature