signdoctors’ referralyellow pageswebsitegoogleonlinefriendflyerother

Your Personal Health Information and your Health Record may be collected, used and disclosed for the following reasons:
For communicating with other treating medical professions, for follow-up/reminder calls, for discussion with third party insurers, accounting/Medicare/health insurance procedures, disease notification as required by law, for use by all physiotherapists in this practice when consulting with you and for legal disclosure as required by a court of law.

If you have any concerns or wish to restrict access to your information please discuss these with your physiotherapist or receptionist. This practice adheres to national Privacy Principles ( and has a written policy available for your perusal.

Your “Informed Consent” is required for all treatment provided by this practice.

  • You may withdraw your consent at any time. Treatment will cease if withdrawn.
  • If you become uncomfortable with your treatment at any time please inform your physio.
  • All forms of treatment carry some risk. Risks will be explained prior to treatment at which time you may choose to continue or discontinue treatment.

If you have a Pension or HCC (low income) card please present to reception for discount.

Are you making a claim for this injury through any of the following?

NB It is your responsibility to provide the following information and documentation required to enable third party billing.

WorkCover (or similar)

If Yes please Provide the following


If Yes please Provide the following

Veteran’s Affairs

If Yes please present DVA gold card and referral to reception

Medicare (Enhanced Primary Care Program

If Yes, please present Medicare card and Referral to reception



As a Physiotherapy practice providing comprehensive care, we focus on your ability to be healthy. Our goals are: firstly, to address the issues that brought you to this practice; secondly, to treat the cause of your condition (not just treat the symptoms or place a temporary patch over your condition); and thirdly, to offer you the opportunity of improved health potential and wellness services in the future. On a daily basis we experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health. Most times the effects are gradual: not even felt until they become serious. Answering the following questions will give us a profile of your health.

ConstantIntensity variesSharpTravelsComes and goesintensity doesn't varyShootingRadiatesAchy

Pins and needlesTinglingNumbnessWeakness

About the sameGetting betterGetting worse

SittingStanding up from a chairWalkingOther


Other health professionals seen for this problem (please list):



High blood pressureCancerSpinal fractureSpinal fractureOsteoporosisSpinal surgeryHeart problemsRheumatoid arthritisDislocationsStrokesAnkylosing spondylitisLigament injuriesDiabetesPsoriatic arthritisCartilage injuriesA pacemakerReiter’s arthritisOsteoarthritisAn aneurysmSpinal traumaDizziness

Latrobe Valley Physiotherapy & Sports Medicine Clinic
Telehealth Client Consent Form

By Signing this consent form, I agree that:
I understand that the benefits of telehealth/video conferencing therapy sessions can include

  • Continued access to my therapist during the COVID-19 pandemic
  • Continued Therapeutic support as part of my treatment plan.
  • Avoiding the need for me to travel to my physiotherapist and increase the risk of exposure to myself and others.

I also understand that there are potential risks and down sides of telehealth/video conferencing therapy sessions, and that these can include:

  • Telehealth/video conferencing may not feel the same as face to face sessions
  • There could be technical problems that could affect the video/sound quality of connection, and this may disrupt the session in some ways.
  • Although my physiotherapist choose video conferencing software, which has end-to-end encryption and high security standards, there is still a small risk of hacking or others tapping into the cideo connection.

I understand that my physiotherapist is taking the necessary precautions to ensure confidentially including:

  • Ensuring the privacy of telehealth sessions is upheld in the same way as an in-person session would be, by choosing a private Location or using headphones.
  • Not allowing any voice or video recording of the session

I have been informed of and understand the payment/medicare processes for my telehealth session, and consent to comply with these.

I understand that i can ask question about the telehealth sessions at any time.

Contact Us

Please Fill out form below. alternative Contact us directly as we are always happy to answer any questions you may have or if you wish to arrange an appointment. 


9 Breed St. Traralgon

Closing in 2 minutes


Shop 1 & 2 Shaw’s Arcade
36 George St. Moe

Sorry, we're closed