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Welcome
to Central City Physiotherapy
Title
(Mr, Mrs, Ms, Miss) Surname……………………………First
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(optional)……………………………………………………… Company……………………………………………
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requiring treatment …………………………………………………………………………………………………………………
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you referred by a Doctor? Y/N Referred
by………………………………………………………………………………
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you have Private Health Cover? (Please
circle)
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understand that I am responsible for the cost of my treatment and any
other expenses incurred by myself.
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