Telehealth Form Flex Physio

Request a Telehealth video consultation

Please fill out the following form and click the 'Submit' button.

This form will be emailed to Flex Physiotherapy, and we will contact you to arrange a suitable appointment.

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Fields marked with an asterisk (*) are required.

Patient details

Patient Name:*

Date of Birth:*

Mobile Phone Number:*

Email address:*

Your Location (Suburb, Town/City, State, Country)*

Referral Source (How did you find out about Flex Physio?)

Referral from health professional Internet search Word of mouth I have been a patient at Flex previously Other

Device you will use (tick any you have access to):

Desktop Computer with Camera Laptop with Camera Mobile Phone iPad or Tablet

Body Area (where is your injury or pain?):

Briefly describe the problem:

DISCOUNT CODE (front-line COVID-19 healthcare workers)

Consent to communicate via video camera

By submitting this form you consent to have a Flex Physiotherapy team member view you by video camera. No recording of this video will be taken without your express consent.