New Patient Form, PowersHealth

Patient Details and Informed Consent *

First

Last

Prefered Name

Address: Number Street Suburb Postcode *

Mobile Phone Number *

Phone Number Other

Email *

Occupation *

Date of Birth *

Who referred you to this clinic/ How did you find out about us

Are you receiving Government Pension or allowances

Pension
Student
DVA
Other

Sports/Hobbies

Who is your General Practioner? *

Are you pregnant?

Are you seeking treatment for a work related injury or Motor Vehicle accident. If yes please provide claim number and insurers details.

PLEASE READ THIS FORM AND PRESS SUBMIT to accept and send completed patient details with consent and waiver: Informed Consent to Evaluation/Testing /Treatment. In this clinic we use a variety of techniques to help you to heal and recover. Our focus is always the benefit of the patient. The nature of chiropractic treatment: The Doctor will use his/her hands or a mechanical device to move or stimulate your joints. For those patients who desire and in fact need a classical manipulation they may feel a ‘click’ or ‘pop’, such as the noise when a knuckle is cracked, and they may feel the movement of the joint. Various ancillary procedures may be used, including hot or cold packs, electric stimulation, traction machine or manual traction, therapeutic ultrasound, and dry hydrotherapy laser treatment. However very often for those that are frailer, methods such as mobilization and stimulation of the joint are more likely to be used. Possible risks: As with any health care procedure, rare complications are theoretically possible following a chiropractic manipulation. Extremely rare complications could theoretically include fractures of bone, muscular strain, ligaments sprain, dislocations of joints, or injury to intervertebral discs, nerves, or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications. The occasional risk with our treatment is more likely to be some soreness or bruising which is part of the healing process. Probability of Risks: The Risks of complications due to chiropractic treatment have been described as ‘rare’, about as often as complications are seen from taking a single aspirin tablet. The risk of cerebrovascular injury or stroke has been estimated at between one in a million to one in twenty million and is further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered ‘rare’. As mentioned, over 25 years of full-time practice we have never seen these. Despite the theoretical risks of these extremely safe and natural treatments it is important to put them in context that they are very much lower than having medication side effects or acquiring an infection in a community setting such as a hospital. Moreover, it is important that problems are treated. In fact not treating them results in a greater risk of the disorder deteriorating. Risks of remaining untreated: Delayed treatment allows formation of adhesions, scar tissue and other degenerative changes which can further reduce skeletal mobility and induce chronic pain cycles. It is probable that delayed treatment will complicate the condition and make future rehabilitation more difficult. Acupuncture treatment: In the hands of a well-trained professional acupuncture is extraordinarily safe, whereas treatment from someone who is untrained or negligent increase the risk of pneumothorax, haematoma, or damaged organ or body part. Sensitive areas: Treated may be anywhere in the human body. To function efficiently, the human body required precise integration of all systems such as the nervous system, muscles, joints and attachments like fascial connections or tendons. Postural and biomechanical analysis and/or reflexology may reveal treatment is required in other areas of the body. and by reflex points that are based on reflexology and meridians/ pressure points. There are over 650 skeletal muscles in the body, over 7 trillion nerves, 360 joints, 206 bones, 20 meridians pathways and over 2000 acupuncture points all functioning as a synergistic whole. By signing this form, you are consenting to testing evaluation and treatment of any of these in a holistic fashion. Traditional acupuncture or western acupuncture or dry needling may indicate acupuncture or acupressure stimulation at locations far from the location of the primary complaint. We may also use dry needling which is the use of acupuncture needles but from a western health model. So treatment may include any of these. If you are unsure why a certain area is being treated, please ask the treating practitioner. As part of evaluation, postural analysis and biomechanical and neurological testing and orthopedic testing methods are utilised. Kinesiology (muscle response testing) may be used to assess the meridians' fascia related to organs and glands from a natural health perspective. The treatment may also involve a combination of herbal/nutritional/diet advice, bach or bush flower essences, homeopathics, exercise, as well as in-house treatment that may include chiropractic, acupuncture, dry needling, guasha, cupping, pressure points, electro or laser therapy, traction machines, mobilising machines, shock wave ESWT therapy, electroacupuncture, meditation and visualisation. People primarily come in for one modality or the other however the vast majority of people come in for relief of a disorder and want the best natural ways to overcome that. So selections from of all these techniques are used to enhance your recovery. If the patient only wants one modality on a particular visit and not the combined effect of several modalities applied one after the other then it is important to inform the practitioner on that visit. Some people think of chiropractic as cracking the joints however there are extremely gentle forms that can be used on extremely frail and old osteoporotic patients as well as newborns. This is more a stimulation of the pressure points around the joints to enhance the body’s healing and alignment. Advice may be given in the form of herbs, nutrients, naturopathy, bach flower bush flowers gem essences use of poultices. It is important to give the practitioner full details of any medications being taken presently but also any past operations or procedures or health conditions that may affect how these natural remedies are applied. Our massage techniques may include methods to anywhere on the body Effleurage (Stroking), Petrissage — Deeper strokes applied by the fingers, thumb elbows or heels of a hand or rarely heels and knees. Kneading, picking up, wringing and rolling are all forms of petrissage. Pummeling and Hacking massage is a percussion movement. Hacking is a light and fast movement performed with the side of hands. Both hands are used to strike muscle areas alternately. Tapotement rhythmic percussion, most frequently administered with the edge of the hand, cupped hands, tips of the fingers or fists. Used for stimulating and toning an area. Forms of this technique include cupping and hacking, among others. Frictions — Applied on the surface tissue, these are rubbing movements on the skin. Vibrations — Generally used to relieve fatigue and pain, these movements can help cure a certain area, creating a natural sedative. Stretching of muscle and fascia using the body parts as fulcrum. Pressure pointing where pressure is applied for sustained periods of time over muscle fascia ligament. Transverse friction massage. Also use of mechanical or electrical massage devices. Rolfing methods may be used which is deep fascial and muscular releases. Our massage therapist may use dry needling if qualified to do that and after verbal consent of the patient but also may use meditation prayer reiki hot stones cold therapy. Our practitioners may use gua sha or graston technique which is a form of scraping technique to help release fascial scar tissue and adhesions. The gua sha may leave red welts on the body sometimes lasting for a week afterwards. Regarding exercises that are given by the Exercise Physiologist, Chiropractor Acupuncturist Massage therapist or Personal trainer or Naturopath. I hereby acknowledge that all the information I have provided to Powers Health Practice/ Power Natural therapies is accurate to the best of my knowledge. If unsure of any information I will inform my practitioner. I understand that to guide myself in exercises the practitioner will be in close physical proximity to myself and may need to stabilise and help with any part of my body for increasing my exercise ability and guiding myself for my posture and motion. I understand that I may require medical clearance from my general practitioner to determine my suitability to commence a regular exercise program. As a patient of Powers Health Practice/ Power Natural therapies it is my responsibility to notify my practitioner if there are any changes to my medical condition including changes in medication. I give permission for Powers Health Practice/ Power Natural therapies to contact my general practitioner or other allied health professionals to obtain any relevant information regarding my condition. I understand that engaging in regular physical activity can cause potential risk of injury or bodily harm and I will not hold the staff of Powers Health Practice/ Power Natural therapies liable if this occurs. Testing and treatment often is done best with the patient changed down to underwear and for females to have a patient gown on if they wish. If the patient is in any way uncomfortable changing clothes down then the practitioner will adapt the procedures to the patient while fully clothed once the patient explains to the practitioner and staff that they prefer to remain fully clothed. Or if the patient does not wish to wear a gown then that is their choice. Some joints, muscles nerves or tissues related to your presenting complaint or related to postural or biomechanical or neurological finding may only be able to be accessed through a body orifice (eg mouth, nostril, ear, rectum, vagina) or may be located in an area that is a “private” area such as the mouth buttocks groin chest breast perineum . If this is the case the patient will give verbal informed consent to the practitioner after the practitioner has provided an explanation as to the reasons for that treatment or examination. For those who wish to have a second professional person in the room during that procedure then a booking can be made where a valid second professional person in the room can be organised and that second person is paid for by the patient separately to the treatment fee. It is the patient's right to have their disorders in any area of their body treated in the most effective and respectful way possible that is supported by medical or natural health literature, professionally and with full dignity. If the patient feels uncomfortable or in pain or distressed in any way during any treatment procedure it is the patient's responsibility to indicate to the practitioner so they can either cease treatment or adapt it to the patients comfort. If the patient at all inadvertently experiences these uncomfortable feelings or is triggered emotionally then it is important to inform the practitioner so that they can respectfully stop and attempt treatment in a different way that is acceptable to the patient and the practitioner. The patient waives all rights to make any legal or complaint proceedings against any staff member or practitioner of Powers Health Practice/ Power Natural therapies or the practice itself as a whole. Any treatment is undertaken at my own risk and I absolve the practitioner and practice of any responsibility and I waive all rights at the initial treatment and all future treatment or consults where I voluntarily present myself to the clinic or have the practitioner do a home visit or treat myself elsewhere. Because some people have experienced trauma in their past then even pressure on someones body may rarely elicit a feeling of anxiety or panic or emotional distress. The practitioner will do all in their power to respectfully and carefully monitor the patient during treatment that is consented to in order to see if there are any indications that the patient is experiencing distressing feelings that are triggered inadvertently. However it is the patient's responsibility to speak up and let the practitioner know if any treatment procedure at all is making them feel uncomfortable in any way. Patients have a right to be treated with care and dignity with our practitioners full ability to help the patients of any part of their body that may be beneficial to the patient. As a result of the above the patient in signing this informed consent is waiving any and all rights completely to proceed through any authority whatsoever or have a third party proceed in any way against the practitioner or the practice on the patient's behalf. If a third party or the patient brings any sort of proceedings or complaint against the treating practitioner or the practice then the patient is here by agreeing to pay the legal defence team of the practitioner or the practice chosen by the practitioner or practice. I hereby agree to release Powers Health Practice/ Power Natural therapies, their owners agents employees contractors and practitioners and agree to hold them harmless for any and all liability claims damages actions whatsoever for loss damages or injury to person or property irrespective of how arising and however caused or during following their instructions pertaining to physical therapy, herbal or nutritional therapy manual therapy and massage and exercise instructions, visualisation or meditation or the facilities and equipment used in conjunction with and or related to such instruction. For the avoidance of doubt this liability waiver shall cover any claims or potential claims arising from or relate to infection from or transmission of communicable diseases including but not limited to COVID-19 or any other communicable disease or virus. I hereby further agree that I will disclose all my physical and medical conditions limitations and sensitivities during any activities related to Powers Health Practice/ Power Natural therapies and their practitioners. I expressly agree that all manual therapy rehabilitative and strength training instruction and herbal or nutritional advice or natural therapy advice and use of all facilities shall be undertaken at my own risk and i represent that i am physically and medically able to undertake physical treatment therapy or rehabilitation and exercise training instructions provided and the activities related thereto. This release of Liability is and all other aspects of my relationship with Powers Health Practice/ Power Natural therapies is governed by the laws of NSW and Australia and I consent to the jurisdiction of NSW. If any portion of this release of liability is found by an appropriate authority to be invalid then the remainder of this liability shall remain in full force and effect. By signing this consent and waiver it gives you protection in that it enables you to claim the benefits of that health profession. It also gives you greater access to potential Medicare and health fund rebates. It enables the practitioner to give you his/her best but at all times under your verbal consent. In addition as a healthcare professional it is important that people who come to see him/her are informed on results they have obtained in the past. This helps patients make an informed decision on their likelihood of success. So in consenting to treatment you are also consenting that your anonymous case (that is reference to your condition and treatment outcomes without in any way referring to you personally) can be used to record the effects of the various treatments that are given and to share that with others. In signing this form either electronically or by hand signature you are stating that you have had the unusual risks of your case explained. I have read the explanation above. I have fully evaluated the risks and benefits of undergoing treatment/therapy/advice. I have freely decided to undergo the recommended treatment and hereby give my full consent to the treatment . We at Powers Health and all staff welcome complaints directed to this practice so that patient care can always be enhanced and that any issues can be resolved in a friendly caring way. Privacy To enable the Practice to continue to deliver and enhance the products and services it provides, the Practice holds personal information about you. We recognise and support your right to full privacy in relation to this information and will continue to handle it with care and in accordance with our professional and legal requirements. The Practice staff will continue to demonstrate integrity and understanding by protecting and keeping secure your personal information. Please take the time to read our Practice’s “Privacy Statement” situated in the reception area. *Your email and address details are taken for many reasons that are for your benefit. It is important to communicate to patients giving them a report of their condition and methods undertaken and to give back-up to the advice given. We may also provide further details of the methods of treatments employed for your benefit. Electronic email is a valuable and simple way of sending information to patients for their benefit. While patients consider themselves to be patients at our clinic we relay additional information occasionally that pertains to their types of health matters in the form of a newsletter and connected health blog. So by giving us your email address and residential address we are able to communicate with you in this manner that is of benefit to you. At no time ever are your details shared with any other person or organization unless we receive your signed request to provide it to them for your own reasons. Please type name in the box provided below.

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