Consent for Physiotherapy


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.


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.