ExoMove Clinic Enquiry Form

General Information

First Name *

Last Name *

Do you identify as Aboriginal or Torres Strait Islander?

YesNoPrefer 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 contacts relationship to you

Health Information

Current GP

Practice

Could you please provide us with details of what you would like help with? Please note any specific conditions or concerns. *

If you are interested in the Lower Limb Device (HAL) we need to know your height (cm) & weight (kg):

How do you mobilise? *

Four wheeled walkerWheelchairForearm Support FrameCrutches/ Walking stick /Other

How much support do you require to transfer? e.g. from sitting to lying *

IndependentOne person assist (with or without lifting aids)Two person assist or more (with or without lifting aids)

Will you attend your appointment with a support person?

Details of concerns listed above *

Things you might like to know before proceeding:

We require a Medical History for our clinician to review and ask that you contact your GP to provide us with this. Please let us know if you require assistance with this.
As different postures & positions for the use of the devices are part of therapy and may increase bladder and bowel urgency, it is advised to consider the timing of voiding your bowel/bladder prior to your appointment. We currently do not have an accessible toilet on site.
Initial consultations are at least 90min in duration. High complexity cases may require longer appointments.
It is not guaranteed that device use will be take place in the initial assessment. The priority for this appointment is to ensure your suitability and safety.
Following initial assessment, up to 3-4 sessions may be required to determine the required treatment plan.
Lower limb device sessions are 1.5hrs in duration minimum.
Fees for ExoMove consults consist of a consult fee and device hire fee.
Priority parking is available, please ask our team for more information

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?