Book Telehealth Appointment

Please enter your details below and our team will contact you to confirm your suitability, appointment time and payment options

Patient Name
Date of Birth
Mobile Phone Number
Email
Dominant Hand
- Right Hand
- Left Hand
- Ambidextrous
Occupation*
Sports or hobbies
Device you will use (tick any you can use)*
- Desktop Computer with camera and sound
- Laptop Computer with camera and sound
- Mobile Phone
- Ipad or Tablet Device
Internet Access
- Broadband via cable on device
- Broadband over wifi
- Mobile Phone network
Physiotherapy Questions
Please give as much detail as you can to allow our Physiotherapists to give you the best possible care
Body part/location of injury or pain*
Describe the issue in as much detail as possible*
What activities make the pain/problem worse?*
What activities make the pain/problem better?*
Have you had treatment for this issue?*
- Yes
- No
With:*
- None
- Doctor
- Physiotherapist
- Exercise Physiologist
- Specialist
Xray/MRI/CT Scan/Ultrasound (tick any that apply*
- Xray
- Ultrasound
- MRI
- CT Scan
What was the name of the radiology place*
Medical History - injuries, medical conditions and diagnoses you have had*
Current Medications*
Consent
By submitting this form you consent to a Kelmscott Physiotherapy team member view you by video camera. No video recordings will take place without your written consent

Physiotherapy Questions