Sports Medicine Patient Information Form

Important Privacy Notice

Information collected by us about you will be stored according to requirements of Federal Privacy legislation. lt will only be passed on where appropriate to the care of the medical problem about which you consulted us (e.g. to your physio or local doctor), or where legally required. lf you require more information, ask a staff member or your treating doctor.

Please fill in all fields or use “n/a” where not applicable.

Click here to download a PDF version to print.

e.g. He/She/They/Other
Media & Recording Consent: Photos and videos of you may be used for educational or marketing purposes on social media. Your identity (such as your face or name) will not be shown. Artificial Intelligence (Al) may be used to record your consultation to assist with transcription. A summary letter will be sent to your referring practitioner and to you. If you do not wish to participate in either of the above, please speak to you practitioner before your consultation.