Pondera New Patient Consent Form

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First Name*

Last Name*

Postal Code*

Birthday*

Mobile Number*

Your Medicare Card Number*

Reference Number*

Medicare Expiry Date*

How did you hear about Pondera or did someone refer you?*

Internet searchAdvertisementGP or specialist (fill consent below)Friend or familySchool or TeacherOther

Which one of our services is the main reason for your visit today?*

SportsGeneralExercise PhysiologyPilatesMassagePerforming Arts ( Dance, Voice, Instrument)\

Do you give Pondera consent to contact your referrer?*

Who is the referral from?*

General practitionerMedical specialistOther Health professional

Referrer's First Name*

Referrer's Last Name*

Privacy and Confidentiality Policy

Privacy and Confidentiality: I consent to the sharing of my information with other services e g. insurance, specialists and other health professionals associated with the management of my treatment. This includes but not limited to copying reports, Doctors' referrals and letters. These documents are used with care and confidentiality by clinicians to help them provide the best care specific to your needs.

Referrer's Last Name*Do you give Pondera consent to share clinical notes/reports?

YesNo

** Federal legislation states that consent is needed for us to fulfill privacy and confidentiality requirements outlined in the Privacy Amendment (Enhancing Privacy Protection) Act 2012, to protect your personal information.

Cancellation policy

All bookings at Pondera are considered clinical appointments. A cancellation fee of 50% of the service fee for appointments or a full session charge for Pilates studio sessions may be applied if you do not advise us in advance of your inability to attend an appointment. To avoid any fees please text, email or call us if you cannot make your appointment or any of your Pilates sessions.

I have read and understood the cancellation policy*

Parent/ Guardian Name if under 18*