Welcome Back!

Long time no see! We are very excited to welcome you back to our practice.

Please take a few minutes to fill this form out to update your file for your practitioner. If you have any questions, we will be glad to help you. We look forward to working with you again in maintaining your health.

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MEMBER DETAILS

Mr
Mrs
Miss
Dr
Other

Full Name *

Date of Birth *//

Do you need to update your personal details in our system?

Home Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone *

Email *

Yes, I want to receive sms reminders for my appointments

Please note that clients who fail to attend their scheduled appointment will be billed a cancellation fee.

Occupation

Emergency Contact Information (Name, Relationship and Phone No.)

Member Information

Service *

Chiropractic
Physiotherapy
Myotherapist
Remedial Massage
Dry Needling
Cupping Therapy
Hijama Therapy (Wet Cupping)
Yoga Classes

Have you ever seen a Chiropractor for treatment? When?

What is the reason of your visit today? Please describe your current pain and location *

Have you had similar symptoms in the past? if yes, please explain...

Is your pain getting...

Worse
Same
Come & Goes

Have you been treated by a medical physician? If yes, when and where?

Have you ever practiced Yoga before? If yes, what type and level of Yoga?

What is your main reason for taking yoga classes?

Flexibility
Increase Energy
Reduce Stress
Improve Balance
Alleviate Back Pain
Other

How many days a week would you like to practice Yoga?

Health History

Please list any serious injuries such as: falls, head injuries, broken bones, dislocations, surgeries and any other serious medical conditions you have had in the past. *

Please go back as far as you can remember and give dates if possible.

Please tick if any of these are relevant to you:

Breathing or lung problems
Heart problems, chest pain or stroke
High blood pressure, Blood clots
Diabetes or thyroid condition
Any chronic illness
Neck/Spine injury
Epilepsy / Seizures
Any autoimmune disease
Surgery in the past 12 months
Muscle joint or any injury that affects you (neck, shoulder, wrists, knees, ankles, etc)
Pregnancy now or within the last 3 months
Back pain, shoulder pain, sciatica pain
Cancer / Tumor

Do you suffer from:

Fainting attack, blackouts, epilepsy / Seizures
Diabetes or thyroid condition
Any infectious disease, hepatitis A,B,C - HIV
Excessive bleeding problems
Heart problems, chest pain or stroke
Pain
Any chronic condition or illness
Allergies, e.g. Penicilin, latex/rubber, oils or foods
Breathing or lung problems
Surgery in the past 12 months
Cancer / Tumor

Please give details: *

Do you have, or ever had:

A blood transfusion
Fainting attack, blackouts, epilepsy / Seizures
Had Wet Cupping-Hijama before

Please give details:

Please list any medications you are taking regularly (including painkillers, drugs, vitamins and supplements) *

Have you taken any medicine or supplement today? *

Is there any other relevant information we should know about?

People come to see us with different goals and objectives. Please choose one of the options below:

I want symptom relief only. I do not want to know the cause of my problems.
I want symptom relief and I wish to find and correct the cause of underlying problems
I want symptom relief, to find and correct the cause of underlying problems and to maximise my health
Other

People come to get a massage with different goals and objectives. Please choose one of the options below:

Occasional remedial massages (not a specific concern)
Occasional remedial massages (symptom relief)
Ongoing remedial massages (correction of a problem)
Other

Informed Consent to Chiropractic Treatment

Changes to the law now require all chiropractors to warn people of material risks. Chiropractic treatment is recognised as an effective and safe method of care for many conditions. However, as with all medical treatments, there are risks involved with chiropractic care, including but is not limited to: • Your condition becoming worse • Disc injuries, rib fracture, sprains/strains (1 in 139,000 cases in the neck and 1 in 62,000 cases in the low back) (1) • Stroke or stroke like symptoms (1 in 5.85 million cases in neck adjustments) (2) Put in context, chiropractic has been shown to be 250 times safer than anti-inflammatory drugs (3) and safer than driving a car (4). Some people may experience some mild soreness for 24 – 48 hours after their adjustments, especially when their body is unwinding. This is a normal sign of change, as may occur after exercise or stretching. Clinical experience consistently demonstrates unexpected improvement in people’s life. One study indicated that 23% of people experience improvement in some other aspect of their health (5). And from those individuals who experience such improvements: • 26% experienced improvements in their respiratory system; • 25% in their digestive system; • 14% circulatory system/heart; • 14%: eyes/vision. REFERENCES (1) Dvorak study in Principles and Practice of Chiropractic, Haldeman, 2nd Ed. (2) Arterial Dissections Following Cervical Manipulation: The Chiropractic Experience. Haldeman S et al. Canadian Medical Association Journal, Vol 165, No 7, 905-906, 2001. (3) A Risk Assessment of Cervical Manipulation vs. NSAID’s for the Treatment of Neck Pain. Dabbs V, Lauretti W. J Manipulative Physiol Ther 1995; 18(8);530-6 (4) What are the Risks of Chiropractic Neck Adjustments. Lauretti W. JACA 1999; 36(9);42-47. a. Leboeuf-Yde C, Axen I, Ahlefeldt G, Lidefelt P, Rosenbaum A, Thurnherr T. The types of improved nonmusculoskeletal Side effects of chiropractic treatment: a prospective study. Leboeuf-Yde C. J Manipulative Physiol Ther. 1997 Oct;20(8):511-5 (5) Frequency and characteristics of side effects of spinal manipulative therapy. Senstad O et al. Spine. 1997 Feb 15;22(4):435-40; discussion 440-1. (6) Symptoms reported after chiropractic spinal manipulative therapy. J Manipulative Physiol Ther 1999;22:559-64.

Consent to Chiropractic *

I have read and understand the information above.
I do not expect the chiropractor to be able to anticipate or explain all the risks and complications. I wish to rely on the chiropractor to exercise his/her judgment during the course of procedures which he/she feels, at the time, based upon the facts known, is in my best interests.
I have, to the best of my knowledge, provided the chiropractor with a complete and accurate health history. I have had the opportunity to discuss with the chiropractor the nature and purpose of chiropractic adjustments and other procedures as well as other concerns. I understand that results are not guaranteed. I intend this consent form to cover the entire course of my chiropractic care for this and any future presentation.
I hereby request and consent to chiropractic examinations, adjustments and other chiropractic procedures wherever the chiropractor determines necessary. By signing below I agree to chiropractic care.

Patient Pre-Treatment Information:

Whilst Hijama (Wet Cupping) Therapy is a traditional technique that has been used for many centuries and has no major side effects, there may be some minor side effects that you should know about and understand. Recipients of Hijama Therapy should understand and accept that there will be marks that will last for at least a few days, with a possibility of a couple of weeks to fade away. Circular discolorations may appear where the cups were applied. Though the discolouration may look like ‘bruises’, they are not. The discolouration is caused by suction (negative pressure), resulting in increased circulation and vasodilation (a widening of the blood vessels). Hijama Therapy may involve minimal discomfort due to the method of application of several light skin cuts to the outer epidermis of the patient (similar to paper cuts). It is possible that for some clients this may result in tiny scarring, depending on the individual. You may also experience slight light-headedness post cupping therapy; this is similar to the sensation one feels after having had blood taken by a doctor as cupping therapy encourages blood flow to the cupped region (hyperaemia). There is also a possibility of fainting with certain people.

Privacy Policy

Information gained from this form will ensure you are provided with the best possible treatment. This information is kept confidential and will not be passed on without patient consent. It may be necessary to discuss your condition and/or treatment with your health practitioner.

Consent to Treatment *

I have read and understand the information above.
I do not expect the practitioner to be able to anticipate or explain all the risks and complications. I wish to rely on the health practitioner to exercise his/her judgment during the course of procedures which he/she feels, at the time, based upon the facts known, is in my best interests.
I have, to the best of my knowledge, provided the health practitioner with a complete and accurate health history. I have had the opportunity to discuss with him/her the nature and purpose of treatment and other procedures as well as other concerns. I understand that results are not guaranteed. I intend this consent form to cover the entire course of my treatment for this and any future presentation.
I hereby request and consent to examinations and other health treatment procedures wherever the practitioner determines necessary. By submitting this form, I agree to health treatment.

DECLARATION: *

I hereby declare that all the information I have given within this form is correct and true to the best of my knowledge, and that no material information has been omitted. I have read and understood the various sections of this form and acknowledge that by signing all the sections of this form I agree that I am voluntarily undergoing this therapy exclusively for wellbeing purposes. I give my consent to SA Wellness Centre to perform Hijama (Wet Cupping) Therapy on me for wellbeing purposes. In giving this consent of my own volition I understand the potential risks and side effects of Hijama Therapy and absolve and indemnify the practitioner and SA Wellness Centre absolutely of any and all liabilities that may arise during and as a result of undergoing Hijama Therapy.
If I experience any unplanned pain or discomfort during any session, I will immediately inform the practitioner performing the service so that all necessary analysis, examination and/or adjustments can take place to ensure client safety and comfort. I further understand that any practitioner’s advice should not be construed as a substitute for a medical examination, diagnosis, advice or treatment.
I agree to keep SA Wellness Centre informed at all times as to changes in my medical conditions and medical profile during all sessions, and I understand there shall be no liability attributable to SA Wellness Centre, and any or any of the staff and practitioners, should I fail to do so. I understand illicit language or remarks by me will result in the immediate termination of the session. I understand that any contraindications or allergic reactions to any service provided by the practitioner will only occur within 24 hours following the service, and that after this time I acknowledge and agree that SA Wellness Centre shall not be responsible or liable for any subsequent complications.

Privacy Policy

Information gained from this form will ensure you are provided with the best possible service. This information is kept confidential and will not be passed on without client's consent.

Consent to Yoga *

I acknowledge that I am a participant in this class. I understand that is my responsibility to participate to my level of physical, mental and emotional ability at all times.
It is my responsibility to inform my practitioner of any illness, injury or medical condition that I may have currently, or have had in the past, that might affect my ability to participate.
I release any facilitator of SA Wellness Centre of any liability in the event that I become injured, sick, disabled or die.
All information provided on this consultation is presented for general, educational and informational purposes only and is not intended as substitute the advice provided by your GP.

Accounts & Billing

Do you intend to claim any rebates through your private health insurance?

Please provide your health fund details (Name and membership No.)

Do you intend to claim your consult through any of the options below? (please specify)

Department of Veteran Affairs (DVA)
Medical Doctor's referral (EPC)
Return to Work SA (RTWSA)
None of the above

Veteran Affairs No. (Please especify if it is a Gold or White Card)

I understand that: *

Full payment is required on the day of consultation regardless any health fund benefit that may be paid.
Any RTWSA, EPC and DVA referrals need to be provided and approved prior to any consultation.
I understand that I am responsible for any treatment fees not paid to SA Wellness Centre by RTWSA, MEDICARE & DVA.
I hereby agree to pay all financial charges arising from my consultations and associated services provided by SA Wellness Centre.