CFIH New Client Intake Form

Please fill in all your details carefully, this will ensure a fast and accurate response from our team. Fields marked with an *asterisk are compulsory.

Your privacy is important to us. Form submissions are encrypted and secure, and you can read our privacy policy here.









Client Details

Title


Gender*




I would prefer to be contacted by:
EmailPhone

Ethnicity/race*


Gross weekly family/household income*

Highest level of education completed*


Medicare & Health Insurance Details


Medicare individual reference number (eg 2)*
Medicare Expiry Date - Month*

Medicare Expiry Date - Year*

Your Medical Information



Medical History (check any and all relevant)*
AsthmaBlood PressureCOPDDiabetesEating DisorderFaintingGastro-intestinal problemsHeart diseaseKidney diseaseLearning disordersMenstrual ProblemsMusculo-skeletalAnxietyDepressionOther Psychological/Psychiatric conditionsSeizuresSleep disordersStrokeSurgeryThyroid issuesSerious injuryNone of the above



I give permission for CFIH to send my GP and other treating professionals a letter notifying them of my intended attendance at the clinic*

I give permission for CFIH to obtain my pathology records and contact my GP requesting additional medical information*

Have you recently been discharged from hospital?

Recently includes within the past 3 months*

How did you hear about us?*

To complete your submission please tick this box:    *compulsory
This is to verify all the information you're submitting is true and accurate to the best of your knowledge and also that you understand our privacy terms and conditions

Signed Consent To Treatment

Prior to beginning treatment, the Treatment Consent Form must be signed.

This will be given to you upon arrival at the clinic for your initial appointment, please arrive 10 minutes early to complete.

Correspondence

CFIH will send sms reminders and emails to the contact information provided, please speak with reception if you have any concerns.

Thank you and we look forward to seeing you soon!

For Current Clients

If you're a current or ongoing client of the clinic, please:

book your next appointment here

For New Clients

If you would like to book your first appointment with us, please:

book a day and time to visit here