I hereby agree to consent to treatment by an appropriately qualified provider for the purpose for providing comprehensive 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.
Go to book a consultation and choose a new time/day and book it in. Then email us with your booking to cancel. Alternatively email or call us and we can help you with the change. To prevent a lot of emailing back and forth, choose a timeslot via Book a Consultation or let us know what days/times work best.
Change fee
We understand that things happen and you may need to change your booking time or day.
Frequent or excessive changes affect our ability to provide the best care to our clients. If excessive or frequent booking changes occur, we will discuss this with you to find a solution. If it continues, we may charge a change fee of $30.
I understand that I am liable to pay for:
Any private treatment or copayment charges for ACC treatments and/or any treatment that is declined by ACC or other funder.
If I fail to attend my appointment or cancel without 24 hours notice I may be charged a $50 fee.
If I fail to pay for my appointment at the time of treatment I may be charged an account administration fee.
The costs of materials such as orthotics, materials, products etc I understand that if this service requires engaging 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. I consent to a discharge/update report being sent to my doctor or medical centre.
I DECLARE - That the information I have given in this form is true and correct.
I AUTHORISE - ACC to collect medical and other records which are or may be relevant to my claim. The treatment provider to lodge this claim for me.
