Patient Details

Emergency Contact

GP Information

Referrer Information (if different from GP information)

Please tell us who to thank for referring you to our clinic

(if different from above GP details)

The below information is for patients being seen under workers compensation, department of veterns affairs or motor vehicle accident. 

If the below does not apply to yourself, please continue to the next and final page. 

Thank you. 

Department of Veteran Affairs (complete if applicable)

Motor Vehicle Accident (completed if applicable)

Workers Compensation (complete if applcable)

Privacy Statement

Your personal health information and your Records may be collected, used and disclosed, including but not limited to, the following reasons: 

  • For communicating relevant information with treating doctors, specialists, insurers or other allied health professionals

  • For use by all clinicians in this group practice, when consulting you

  • For research purposes (de-indentified, meaning you are not able to be indentified from information given)

If you have any concerns or wish to restrict access to your personal health information, please discuss these with your treating clinician. 


DECLARATION: I understand and agree that: 

  1. If I am unable to attend my appointment I will give 24 hours notice of my cancellation. If I do not cancel with notice I will be charged a Non-Attendance Fee for my missed appointment. 

  2. I am required to pay on the day for all consultations. Body Logic Physiotherapy accepts, cash, cheques and has EFTPOS and HiCaps facilities. If my account is not paid at the time of consultation, administration feed maybe added. 

  3. In the event that my accounts are outstanding longer than 45 days, I will be responsible for all collection fees incurred. 

  4. For insurance claims, I will be personally responsible for payment of all accounts incurred by me in the event that liability is denied, or placed in dispute by the insurance company.  

  5. I consent to treatment provided by the clinicians.

Draw signature|Type signatureClear

We are following the up-to-date advice from WA Government Health Directives and good practice guidelines as outlined by AHPRA. However, we will implement additional changes as necessary. In the meantime, you can feel confident that we have the following practises and policies in place to keep you safe.

What are we doing to keep you safe at our Shenton Park practice: 

  • All our treatment rooms, gym and reception areas are fitted with air purifiers with HEPA filters - proven to be effective to remove COVID-19 from the air

  • Extra cleaning protocols have been implemented throughout the clinic


  • The Physiotherapists are fully vaccinated and wear N95 or equivalent masks for close contacts

  • The Physiotherapists will not attend the clinic if they feel unwell

  • The Physiotherapists adhere to recommended sanitising protocols

Administration team:

  • Our admin team are fully vaccinated and wear N95 or equivalent masks

  • Our admin team members will not attend the clinic if they feel unwell

For our patients:

  • We will be treating patients face-to-face in our clinic (or via Telehealth if you would prefer)

  • To assist us meet the new WA State Government guidelines we kindly ask our clients (12 years and older) to wear a mask whilst you are visiting the clinic.

  • We ask if you are feeling unwell and have an appointment with us to please contact us to reschedule your appointment


  • Telehealth appointments are available to all patients

  • High quality physiotherapy care can be effectively provided via Telehealth

  • To find out more information on Telehealth, please click here 

We are open with our normal operating hours, and welcome any questions you may have. We encourage you to stay in touch with us during this challenging time.

We will continue to update our Covid responses in line with government and health directives. 

If you would like any more information, please do not hesitate to talk to your physiotherapist. 

Draw signature|Type signatureClear

Intake Questionnaire

Please answer the following questions to ensure that we have a thorough understanding of your past and current heath.

Body Chart

Please look at the image below and draw any areas of pain and/or pins and needles and altered sensation.

(We have also provided a decription box below the image, if you would like to provide further information)

Clear drawing

Orebro Musculoskeletal Pain Screening Questionnaire

Here are some of the things which other people have told us about their pain. For each statement please select one number from 0-10 to say how much physical activities, such as bending, lifting, walking or driving affect your pain.