_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

You MUST have a Referral.
Please contact your Doctor/Specialist to organise your referral.

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

Advanced Spine & Pain will endeavour to gain all necessary Authority and permission required, to treat you under the terms and conditions of your insurance.  In the event your insurance company denies your claim or fails to pay the fees you incur at this or at our affiliated facilities, you acknowledge and accept the costs incurred for your treatment in your consultations and procedures.

On the day of your consultation, payment is processed and Advanced Spine & Pain may either hand you a printed copy of your receipt or send it to you electronically to the email address you have provided.

Advanced Spine & Pain will lodge your Medicare claim, on your behalf (appliable on all Medicare Item numbers).

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

Consultations

Should you cancel your consultation within 24 hours of the appointment time you will be charged a cancellation fee. The cancellation fee is 100% of the consultation fee. This fee will be debited from your nominated credit card.

Procedures

Should you cancel or rebook your procedure within 24 hours of the appointment time you will be charged a cancellation fee of $250.00. This fee will be debited from your nominated credit card.

*Workers compensation Insurance companies will not pay this fee therefore you, the patient, will be liable to pay all cancelation fee(s).

Should there be any outstanding fee that has not been paid within 7 days of invoice, you will be referred to a debt collection agency. The account will incur an additional 30% debt recovery fee charged as the ‘Collection Fee’ and this will be added to the total amount outstanding.

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

• The following pages contain a number of questions that relate to how your pain impacts on your life.
  
  

• Your answers will allow us to appreciate the consequences of your pain on your overall well-being.
  
  

• Answer each question honestly as these answers will assist the Doctor to fully assess your individual situation.
  
  

• You may answer the questions in one sitting or you may take breaks in between sections to avoid survey fatigue.
  
  

• When you click the 'submit' button, your form will be automatically sent to Advanced Spine & Pain staff.

If you choose to " Save and Complete Later " after the NEXT button at the bottom of each page
please make sure you  enter your email address  and press  Send   when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches).

No Pain

Pain as bad as
you can imagine

Please choose the one percentage that most shows how much relief you have received:

No Relief

Complete Relief

Select the one number that describes how, during the past 24 hours, pain has INTERFERED with your:

Does Not
Interfere

Completely
interferes

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

Not
confident
 at all

Completely
 Confident

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, toothache, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery. 

We are interested in the types of thoughts and feelings you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

In these days of high-tech medicine, one of the most important sources of information about you is often missing from your medical records, which is your own feelings or intuitions about what is happening with your body. We hope that the following information will help to fill this gap. 

Using the following scale, please indicate the degree that best corresponds to how you feel. Please rate each statement below according to your own feelings, not what others suggest you should believe.  This is not a test of medical knowledge; we want to know how you see it.

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

Please read each statement and select the option which indicates how much the statement applied to you over the past week. There are no right or wrong answers.  Do not spend too much time on any statement.

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

This questionnaire is designed to give us information about how your back (or leg) trouble affects your ability to manage in everyday life.   Please answer every section.  Select one box only in each section that most closely describes you today.

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

_______________________________________________________________________________________________________________________________________

If you choose to " Save and Complete Later" after the NEXT button below
please make sure you enter your email address and press Send when prompted.

When ready to complete the form again, use that email (not the original Advanced Spine & Pain email) to click on the link.
You will then be returned to your form, with the information you previously entered.   

 Associated with your treatment at Advanced Spine & Pain, personal details and medical information will be collected. The Australian Privacy Principles dictate that we require your consent to use your personal information. We use your personal information for the reasons outlined below:

• To facilitate data collection and reporting of outcomes which may be used for quality improvement, development of service delivery, and planning at Advanced Spine and Pain.

• To inform your next of kin or authorised representative whom you have nominated, of the outcome of treatment, eg. an enduring power of attorney, guardian or carer.

• To enable us to provide information to authorities such as Medicare, Veterans Affairs, health funds, Commonwealth and State departments, as well as inform Third Party certification bodies who may audit against compliance to the Privacy Principles.

• To inform other medical practitioners or institutions who may treat you in the future, but only to the extent necessary to treat the particular conditions. This may include the exchange of information, eg previous test results.

• To assist in providing practical training and education to medical, nursing or allied health professionals, such as physiotherapists and rehabilitation specialists.

• To provide your contact information to Australian Medical Research (AMR) and be informed of upcoming clinical research studies that you may be suitable to participate in.  AMR is associated with Advanced Spine & Pain and manages clinical trials for new medications, techniques, and devices.

• To provide AMR with your clinical data for research purposes, your name will be removed. You will, therefore, not be identified in any research publications that result from this.

NOTE: If there is anything in this document that you do not understand or if you have any questions, please do not sign until you have had your questions answered to your satisfaction. 

Please refer to the Privacy Policy displayed at Reception for further information regarding privacy.