ExoMove Clinic Enquiry Form
General Information
First Name
*
Last Name
*
Title
Mr
Ms
Mrs
Miss
Dr
Other
Do you identify as Aboriginal or Torres Strait Islander?
Yes
No
Prefer not to say
Date of birth
*
Email Address
*
Home phone
Mobile phone
*
Home address
How did you find out about us?
Emergency Contact Information
Emergency contact
Phone
Emergency contact’s relationship to you
Health Information
Could you please provide us with details of what you would like help with?
*
Current GP
Practice
Consent
Kinetic Medicine will treat my information as private and confidential, I acknowledge my consent for Kinetic Medicine to communicate with the people in my care team (e.g. GP, insurer, NDIS stakeholders, etc) when it is necessary to my care.
*
I acknowledge that, where fees are liable, that these are to be settled prior to or at the time of my appointment. Failure to provide 24hrs notice of cancellation or rescheduling may render me liable to the fees for my consult.
*
We are a teaching practice and often have students in the clinic, do you consent to them being present in your consults?
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