Client Intake Form

Title MrMrsMsMissDr

First Name (required)

Surname (required)

Preferred Name

Parent / Guardian Name (if you are under 18)

Date of Birth

Your Email (required)

Address

Phone (Home)

Phone (Work)

Phone (Mobile)

Your Occupation

Who referred you to Evolve Manual Therapy?

Do you have private health insurance?
YesNo

If yes, with whom?

What is the main purpose of your consultation?

Were the injuries/condition for which you are now seeking treatment possibly related to a motor vehicle accident or work related injury? YesNo

* Please note, Evolve Manual Therapy is a private clinic and does not take motor vehicle accident or workers compensation claims. However, we would be pleased to see you as a private client.

Release / Obtaining of Medical Information

It may be necessary for the consulting therapist to exchange information regarding your condition with your general practitioner, naturopath or medical specialist:

I,
give permission for representatives of Evolve Manual Therapy to exchange information regarding my condition.

Cancellation Policy

Please be aware that Evolve Manual Therapy has a 24 hr cancellation policy (Business Days Mon-Fri). Less than 24 hrs notice will incur a fee of 50% and non-attendance will require the full fee to be paid.

I have read, understood and accept the conditions above. I accept personal responsibility for account settlement. I understand that failure to give 24 hours notice for cancellations will incur a fee equal to 50% of the scheduled fee. I understand that non-attendance at a consultation without notice will incur the full fee for that consultation.

Type your full name here:

Today's Date:

If under 18 years of age, signature of the parent, guardian or next of kin is required.