Patient Forms

How did you hear about us?

Social Media

Friend

Relative

Existing Patient

Are you allergic to or had a bad reaction to any of the following? If yes, please tick the appropriate box/boxes

If yes, please list all related prescribed medications in the space provided.

If you are experiencing any of the following due to the area of injury, please tick yes where applicable:

Please read the following carefully and tick if you agree or mark (x) if you disagree, in the box provided.

I understand that the information I’ve provided on this form may influence my treatment and that the information, is to the best of my knowledge, true and accurate.

I hereby permit Optimum Orthopaedics to hold this form on file and hold my clinic records.

I understand that the information will be kept in confidence and not shared with any third party unless prior written consent had been provided.

I consent to the examination, which includes the use of touch and some non-invasive instruments. After this, appropriate treatment(s) will be proposed to me (the medical patient), which I have the right to opt out of, ask questions about or consent to.

I agree to photography and videography of my treatment (does not include facial, any distinctive marks, such as tattoos, birth marks, piercings, etc.) in relation to my treatment and to aid any referral information to other health professionals by agreement to maximize treatment.

General Information

In case of an emergency, who should we contact?

Medical History

Do you have a history of medical problems?

Surgical History

Medical History Continued

Protection Compliance Declaration

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