Make A Referral

Our aim is to see all clients within our service area (below) within 24-48 hours.

Client Name *

First

Last

Phone *

Email *

Client Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Date of Birth *//

Gender

Male
Female
Prefer not to say

Emergency Contact / Relationship

Emergency Contact Phone Number

GP Details

GP Practice Name

Details on condition / Why is Physiotherapy or Exercise Physiology required? *

Funding Type *

NDIS
STRC
HCP
Private Health
DVA - Referral Required
Workers Compensation / CTP
Medicare - CDM
Other

NDIS Plan Management

Self Managed
Plan Managed
NDIA Managed

How do you manage your NDIS Funding?

Self Managed Email

Please enter the email that Physio Pal will send an invoice to the participant (or their Nominee) to pay.

Plan Manager Name

Plan Manager Phone

Plan Manager Email

Physio Pal will claim payment from your Registered Plan Manager.

Private Health Details

Member Number

Initial Report Required?

Referring Organisation

Referrer Name

First

Last

Referrer Email

Support Coordinator Name

First

Last

Support Coordinator Email

Support Coordinator Phone

STRC Pre-approval

Initial Assessment + Report
Pre-Approval for 15 Sub x Physiotherapy Sessions
Pre-Approval for 7 Sub x Physiotherapy Sessions
Pre-Approval for Equipment Pack

HCP Funding Level

HCP Pre-approval

Pre-Approval for Initial Assessment and Report Only
Pre-Approval for 10 x Physiotherapy Sessions
Pre-Approval for Ongoing Weekly Physiotherapy Sessions
Pre-Approval for Equipment Pack

DVA Card Number

DVA Card Type

White Card
Gold Card

Work Cover Claim Number

Date of Injury

Claim Manager Name

First

Last

Claim Manager Email

Claim Manager Phone

Insurer Organisation Name

Upload Certificate of Capacity

Click or drag files to this area to upload. You can upload up to 4 files.

Stating Physiotherapy or Exercise Physiology

Other

NDIS Number:

NDIS Plan Start Date

NDIS Plan End Date

(Optional) Funding available for Physiotherapy/Exercise Physiology funding:

Upload NDIS Plan (Optional)

Click or drag files to this area to upload. You can upload up to 4 files.

Upload Referral Information (Optional)

Click or drag files to this area to upload. You can upload up to 4 files.

Please Upload a Copy of the Care Management Plan

Click or drag files to this area to upload. You can upload up to 4 files.

Risk Assessment (Please tick box below if YES)

Is the address above different to where the service will be provided? If yes, provide the address below:
Has the person tested positive to COVID-19 in the last 14 days or experiencing any COVID like symptoms?
Is there any potential risks identified in the medical history of the client?
Does the person have a history of infection? (MRSA,CRE, etc)
Is there any risk of aggression or violence at this location?
Is anyone at the service location given under the influence of alcohol or drugs?
Are there any unrestrained, dangerous or aggressive pets at this location?
Is the service location remote or are there any access issues to the home?
Is there poor mobile phone coverage at the treating location?

To ensure the upmost safety of you, the client and our team, please be sure to read the above options carefully.

Alternative Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

How did you hear about Physio Pal?

Google
Word of Mouth
Current Referrer
Facebook
Instagram
My Support Coordinator
GP
Other

Service Terms & Conditions *

Yes, I agree to the below terms and conditions of service

Cancellation Policy
We ask that patients provide 24 hours notice if they are unable to keep their appointment. Appointments cancelled within 24 hours that are not able to be rescheduled will be charged at 50% of the appointment fee.

Dry Needling Disclaimer
Dry needling (DN) is a skilled technique performed by a physiotherapist using a single-use, single-insertion, sterile filiform needle, which is used to penetrate the skin or underlying tissue to effect change in body conditions, pain, movement, impairment and disability.

Like any treatment there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving your consent for dry needling treatment.

Risks of the procedure:
The most serious risk associated with DN is accidental puncture of a lung (pneumothorax). If this were to occur, it may require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe lung puncture, while rare, may require hospitalization.
Other risks may include bruising, infection or nerve injury. It should be noted that bruising is a common occurrence and should not be a concern. The monofilament needles are very small and do not have a cutting edge; the likelihood of any significant tissue trauma from DN is unlikely.

Other

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Email *

Our Services

In-Home Physiotherapy
Mobile Exercise Physiology
In-home Dietetics
In-home Occupational Therapy
Hydrotherapy (at local pools)
Clinical Pilates (at local studios)

Our Service Area

Campbelltown Council
Camden Council
Southern Highlands + Bowral + Moss Vale
Wollongong and surrounding areas
Bulli, Thirroul, Balgownie and surrounding areas
Shellharbour, Dapto, Warrawong, Warilla, Albion Park
Kiama, Gerringong, Gerroa, Berry
Nowra, Bomaderry, Huskisson, Vincentia
Ulladulla + South East Coast
Batemans Bay, Moruya, Narooma, Bega

Referrals for:

My Aged Care
NDIS
HCP
Work Cover
Post-Operative
Private Health Insurance
Hospital in home
CTP
Medicare Chronic Conditions

Private Health Funds Accepted:

See list of Private Health Funds

What our clients have to say

**Izak D.** **Albion Park Rail**, **NSW**
**Physio, My Aged Care: Home Care Package**.

“Staff are focused only on my physio appointment and not trying to juggle two or more appointments at once.

Comfortable and less stressful in your own home. Allows more privacy, so no other customers listening and knowing your business.

Less stress with physio at home instead of driving to appointments if you are able to or trying to find someone to take you. Having to find parking that’s close pending on your injury and dealing with unsuitable/uneven pathways to walk on.”

Elaine H. Berry, NSW
Exercise Physiology, Private Client

“Have found all personal contact is always polite and respectful. The visits to our home are punctual and at times convenient for me.

Because of my fluctuating health situation (Parkinson’s) the in-home physio visits are a boon for me. The program Kade has initiated for me has helped me gain more confidence in steadiness and balance. Regular progress checks are made and kept for his future reference.”

Matthew R. Horsley, NSW
NDIS Physiotherapy

“I like in-home Physio as it makes access to physio much less stressful due to my mobility & vision impairments.

I appreciate how polite they are & how they are very good at their job, helping me to achieve my goals.”

Maddox. NSW
Exercise Physiology, Private Client

“Maddox has really enjoyed working with Demi to reach his goals.

Initially Maddox lacked confidence in his ability to do physical activity but has become more confident in himself and finds her sessions at home and at childcare fun.

Thanks for your hard work Demi.”

Make a Referral above or via one of these channels:

Call Us Today

(02) 4202 3874

Email Our Team

admin@physiopal.com.au

Postal Address

131 Belinda Street Gerringong, 2534, NSW

Or make an Enquiry Below:

Name *

How Can We Help You?

Contact Phone Number *

Location