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PERSONAL INFORMATION

Birthday
Day
Month
Year

ACCOUNT INFORMATION

HEALTH FUND
Have you been with this fund for atleast 12 months
YES
NO

REFERRAL DETAILS

EMERGENCY CONTACT

MEDICATIONS & ALLERGIES

Are you taking any medications?
YES
NO
Do you have any allergies?
YES
NO

MEDICAL HISTORY

Do you have any other medical conditions
YES
NO
Have you had prior surgery?
YES
NO

PRIVACY & CONSENT

I understand that The Australian Pelvic Floor Institute (APFI) handles personal information in accordance with federal and state privacy laws. I consent to the handling of my information by this practice for the purpose of providing me with quality healthcare, which includes permitting my medical information to be obtained from any other medical services involved in my care, my medical information to be shared with other treating allied health professionals. I also give permission for my information to be used for associative administrative and billing purposes.


I understand that in order to provide me with the best available treatment and care APFI may be required to perform certain non-invasive diagnostic assessments and or procedures. I hereby give consent to APFI at the discretion of the medical practitioner to conduct such examination/investigations and/ or procedures should they be deemed an essential part of my diagnostic assessment and treatment regime.

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