M3 Patient Rego From M3 Patient Registration Form "*" indicates required fields Title*Please selectMrMrsMsMissDrMxOtherName* First Last Date of birth*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address*Home Phone Mobile Phone* Email* Emergency Contact - Name and Contact Number* Ethnicity Occupation Employment TypePlease selectPaid employment in New ZealandSelf-employed in New ZealandNot in paid employmentWork IntensityPlease selectHeavyMediumLightSedentaryMedical CentrePlease selectBush Road Medical CentreCentral Family HealthManaia HealthOnerahi Medical CentreParamount Medical CentrePrimecare Medical CentreRaumanga Medical CentreRust Ave Medical CentreTui Medical CentreWest End Medical CentreOtherIf other, please state GP Name How did you hear about M3?Please selectRecommended by Health Practitioner / ProviderRecommended by Family / FriendWord of mouthYellow PagesGoogle / OnlineOtherM3 Clinic + Studio - Appointment information. Appointment Type Registering a New ACC Claim with M3 Existing ACC Claim already registered Private Consultation (Non- ACC) Massage Therapy Appointment Dietician Appointment M3 Clinic + Studio - Physiotherapy & Podiatry ACC Claim Details. Please complete the below if you have an Existing ACC Claim for your injury or email a copy of your claim to *protected email*ACC Claim Number Date of Injury (approx if unknown) Body Site injured: (e.g Lower back, Left Shoulder) Mechanism Of injury (e.g Lifting furniture) Imaging Details (have you had any of the following investigations for your injury) X-ray Ultrasound MRI Other ACC Cover Yes, I accept I am liable for ACC charges if my ACC claim has expired, not valid or declined. M3 Clinic + Studio Pre-screening Health QuestionnaireFor your safety and protection, and for our information, please answer the following questions below. Do you have any of the following conditions?:Arthritis* Yes No Site Hepatitis* Yes No Rheumatoid arthritis* Yes No Site Previous radiographic/medial investigation* Yes No Please state Diabeties* Yes No Pacemaker* Yes No Osteoporosis* Yes No Site Previous radiographic/medial investigation* Yes No Please state Pregnant* Yes No History of cancer* Yes No Type Vascular problems* Yes No Type Blood disorder* Yes No Type Epilepsy* Yes No Chest/respiratory problems* Yes No Type Metal/artificial implants* Yes No Type Heart/cardiac problems* Yes No Type Allergies* Yes No Type Other relevant medical history or InjuryRelevant Medications Recent/previous surgery In accordance with the PRIVACY ACT, all information recorded in your files will be kept confidential. Your record will only be accessed by the Practitioner / Instructor providing your care & those office staff responsible for filing. All personnel in this practice are bound to maintain strict patient confidentiality. Under the PRIVACY ACT, you have the right of access to, and correction of, your personal information. No information will be given to a third party without your consent. If you have any concerns or complaints about your treatment you may approach any staff member to discuss your concerns. We’re here to help and have policies in place that will deal with your complaint promptly and fairly. You may also request a complaints form from reception. Informed Consent* I hereby consent to assessment/treatment as may be necessary in support of my illness, injury or condition. I understand that a full explanation will be given prior to assessment/ treatment. I understand I have the right to decline part or all of my treatment being offered. I understand my right to a second opinion and right to have a support person for all appointments. Liability Waiver* I do hereby declare myself to be physically sound and suffering from no condition, impairment, disease or infirmity or other illness (other than those declared on the attached pre-screen questionnaire) that would prevent my participation or use of equipment or facilities except as herein stated. Liability Waiver* I do hereby waive, release and forever discharge M3 from any and all responsibility or liability for injuries or damages resulting from my participation in any activities or my use of equipment or facilities whilst undertaking exercise training in M3 Studio's. Surcharges and Payment* Yes, I accept charges and are required to pay in full at the time of treatment unless otherwise arranged. Cancelation / No Show policy* Yes, I accept If I fail to attend my appointment or cancel within 24-hours i will be charged a No Show or late cancel fee of $40.