Patient Detail Form

Welcome and thank you for choosing Central City Health Professionals

Title (please circle) ( Mr, Mrs, Ms, Miss, Dr, Prof, Other )
Surname………………………………………………………………     First Name…………………………………………………………

Home Address ………………………………………………………………………………………………………………………………………

Suburb……………………………………………………………     State………………………………     Post Code…………………

Occupation ………………………………………………………………………       Company……………………………………………

Home…………………………………………………     Mobile……………………………………………    Work…………………………

Email…………………………………………………………………………………………      DOB………………………………………………

Do you have Private Health Cover? (Please circle)
HBF    MBP    HIF    SGIO    HCF    NIB    GU Health    Other………………………………………………………………

Do you have a Pension Card?   Y  /  N         Card number  ………………………………………………………………

How did you hear about us? (Please circle)

Dr Referral        Flyer       Google        Yahoo        Bloo         Facebook         Hotel       Street Sign   

Other……………………………………………………………          Recommended by ………………………………………………



Area requiring treatment …………………………………………………………………………………………………………………
Were you referred by a Doctor?   Y / N           Referred by………………………………………………………………

Workers Compensation   Y/N

Is this visit related to an injury suffered at work for which you are making a claim:   

………… Yes ………… No

Employers Name ………………………………………………………………………………………………………………………………… 
Contact Person & Phone Number…………………………………………………………………………………………………………
Address……………………………………………
Date of Accident……………………………………………………    Claim No. ……………………………………………………



Workers Compensation Claim Terms and Conditions:

I understand that Central City Health Professionals will allow me to receive treatment without upfront payment for up to 6 visits in order to allow time for my claim to be processed. If by the 6th visit my claim is still in dispute then I agree to make full payment for all fees incurred up until this point and for all further treatment until my claim is resolved. If, during the course of my treatment my account, though not in dispute has an outstanding balance equal  to or more than 6 visits I agree to pay personally for all subsequent visits until payments are received from the insurance company. I have read and understand that if my claim is not accepted by the named Insurance Company, then my accounts and any expenses incurred in the collection of my unpaid account will become my responsibility.




Motor Vehicle Accident   Y/N

Is this visit related to a motor vehicle accident for which you will be making a claim?   
………… Yes   ………… No    
Date of Accident……………………………………………………      Claim No. ……………………………………………………



Motor Vehicle Claim Terms and Conditions

I understand that I will need to pay for all treatment received upfront until Central City Health Professionals receive written notification that my Motor Vehicle claim has been accepted.  I have read and understand that at any stage the Insurance Commission of WA (ICWA) stops paying for treatment that all accounts and any expenses incurred in the collection of my unpaid account will become my responsibility.

Chiropractic Information:

Changes in the law now require all practitioners who manipulate the spine to inform patients
of material risks. In the extremely rare circumstances, some treatments of the neck may damage a blood vessel and give rise to a stroke or stroke like symptoms (approx 1 in 5.85 mil neck manipulations, Haldemant, et al Spine vol 24-8 1999). Whilst this has never occurred in this practice, we are still required to inform you. If any adjustments are require you will be tested to rule out any risks beforehand, as has always been our practice.

Chiropractic adjustments of the spine are internationally recognised as being far safer in dealing with neck and low back problems than medications and other alternatives (As Risk assessment of Cervical manipulation, JPMT, 1995, Manga report, Ontario Ministry of Health, 1993).If you have any questions related to the treatment you are about to receive, please speak to the chiropractor. I have discussed the above information with the chiropractor and given my consent to treatment.

Patients Signature: _________________________  Date _________________________ 

OFFICE USE ONLY:     Physiotherapy            Chiropractic           Podiatry            Massage