BOOKING FORM: ADULT PART B

Yay! 🎉🎉🎉 If you have got this far you have successfully filled out Part A of our booking form.

This next section (Part B) will give us a more detailed picture of your medical history so that we can find the right therapist for you!

You can fill out Part B before or after speaking with our team to confirm your booking. You choose! But please note, this form MUST be filled out before your first appointment with us.

If you have trouble filling out the form, please call us on 07 3395 4400. If we can’t answer, leave a message and we will be in touch with you as soon as we can.

Client's Name

Client's Date of Birth

Client's Age

Email Address

Phone

Emergency Contact Details

Emergency Contact Relationship to Client

Emergency Contact Number

Medical Practitioner | Referring Doctor

Medical and Developmental History And Reports Please provide copies of relevant medical reports File InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

Are there any diagnosed illnesses/disorders? Are there any diagnosed illnesses/disorders? Yes No

Please specify

Have you recently been hospitalised? Have you recently been hospitalised? Yes No

Please specify

Have you had any recent operations? Have you had any recent operations? Yes No

Please specify

Is there a family history of: Is there a family history of: Heart disease High blood pressure Asthma Stroke Diabetes Hearing loss Allergies (like hay fever) Cognitive changes (like dementia) Neurological conditions (like Parkinsons) Digestive conditions (like reflux or ulcers) Other conditions related to speech, language, literacy and communication.

Please specify

Have you been assessed by a Speech Pathologist or received speech therapy? Have you been assessed by a Speech Pathologist or received speech therapy? Yes No

Please specify

Speech Therapy Reports Please provide copies of relevant speech therapy reports File InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

Have you been assessed by another allied health professional (Psychologist, Physiotherapist, Occupational Therapist)? Have you been assessed by another allied health professional (Psychologist, Physiotherapist, Occupational Therapist)? Yes No

Please specify

Allied Health Reports Please provide copies of relevant therapy reports File InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

CONSENT TO TREATMENT

I understand that if I have any questions or concerns regarding my treatment, I should discuss them with the Speech Pathologist before signing this consent. I understand that if I have any questions or concerns regarding my treatment, I should discuss them with the Speech Pathologist before signing this consent. Yes No

I understand that at times, it is important for my clinical information to be shared with other relevant Professionals, such as a GP, a referring Specialist or an Allied Health Professional. I understand that at times, it is important for my clinical information to be shared with other relevant Professionals, such as a GP, a referring Specialist or an Allied Health Professional. Yes No

I understand that a minimum of 24 hours notice is required for appointment changes or cancellations and that those appointments cancelled or changed with less than 24 hours notice may incur a $115.00 fee. I understand that a minimum of 24 hours notice is required for appointment changes or cancellations and that those appointments cancelled or changed with less than 24 hours notice may incur a $115.00 fee. Yes No

I consent to treatment, and I consent to the release of my clinical information to other relevant Professionals if required. I consent to treatment, and I consent to the release of my clinical information to other relevant Professionals if required. Yes No

The information I have provided is correct and complete. The information I have provided is correct and complete. Yes No

Signed Save Clear

Date