NEW CLIENT BOOKING FORM

Thanks for booking your initial consult with Robofit.

Please fill in the below intake form to help our clinicians understand you a little better.

Please note, the purpose of your initial consult is to create a treatment plan and understand your current function and goals.

If you are coming to utilise the HAL robotic devices, this will be discussed in your initial consult. You will be booked in for trial sessions to utilise the devices after discussion with your therapists.

If you have further questions, please call us 1800 560 842

General Information

Client first name *

Client surname *

Date of birth *

Email Address *

Home phone

Mobile phone *

Home Address *

Street address *

City *

State *

Postcode *

Does the client have a Legal Guardian? *

YesNo

Legal Guardian Full name *

Clinician Preference *

Exercise PhysiologyPhysiotherapyEither

How did you find out about us? *

Other: *

Emergency Contact Information

Emergency contact/Next of Kin *

Phone *

Emergency contact’s relationship to you *

Funding Information

DVA File Number *

DVA Card Type

WhiteGold

For White Card holders, please list the Conditions/disability to be treated

iCare Participant Number *

NDIS Participant Number *

NDIS Plan Start Date

NDIS Plan End Date

NISQ Case Number *

Traffic Accident Commission (TAC) Claim Number *

Date of accident/injury related to TAC Claim

My Aged Care Provider *

My Aged Care Package *

Commonwealth Home Support Program (with referral codes)Support at Home (assigned package levels 1-8)Support at Home (restorative care pathway)

Aged Care Provider Case Manager Name *

Case Manager Phone or Email *

Are you happy for us to contact your Aged Care Provider on your behalf to check if your package can fund your sessions? *

YesNo

Support Coordinator Name *Please enter N/A if you do not have one

Support Coordinator Phone Number or Email Address *Please enter N/A if you do not have one

Are you happy for us to contact your Support Coordinator on your behalf to check if you have funding available for RoboFit sessions? *

YesNo

Case Manager Name *

Case Manager Email *

Case Manager Phone Number *

Please provide the email address for the company or person who will pay for the Initial Consultation *

RoboFit is not an NDIS Registered Provider. If you are NDIA Managed, we will not be able to make a claim to the NDIA for this service. If you choose to access our services, you will need to pay for them privately.

Please select "Privately Funded" to complete this form

RoboFit is not a registered provider for Commonwealth Home Support Program. If you choose to access our services, you will need to pay for them privately.

Our services are often covered by Support at Home packages. Please let our team know if you are in the process of applying for Support at Home on 1800 560 842, or hello@robofit.com.au.

Your journey with us starts with an Initial Consultation, where we take the time to understand your health history, goals and current abilities. This session helps your clinician design a personalised plan that's tailored specifically to you.

Pricing for the Initial Consultation is outlined below.

Schedule of Supports

1 hour Initial Consultation

Clinician	Price
Exercise Physiologist	$209.00 (includes GST)
Physiotherapist	$220.00

Schedule of Supports - iCare

1 hour Initial Consultation

Clinician	Price
Exercise Physiologist	$224.40 (includes GST)
Physiotherapist	$224.00

Schedule of Supports - NIISQ

1 hour Initial Consultation

Clinician	Price
Exercise Physiologist	$223
Physiotherapist	$223

Schedule of Supports

1 hour Initial Consultation

Clinician	Quantity	Price
15_200_0126_1_3 Exercise Physiologist	1	$161.99 (includes GST)
15_200_0126_1_3 Exercise Physiologist non face to face	0.21	$34.02 (includes GST)
Total Exercise Physiologogy Initial Consultation		$196.01

15_055_0128_1_3 Physiotherapy	1	$183.99
15_055_0128_1_3 Physiotherapy non face to face	0.17	$31.28
Total Physiotherapy Initial Consultation		$215.27

Communication

Do you have any communication difficulties? *

YesNo

Please choose any or all that are relevant

Hard of Hearing/Hearing impairmentSpeech difficultiesDifficulty understanding speechOther:

Enquiry Information

Diagnosis or Medical Condition *Diagnosis, Area of weakness/impairment/disability

Other Medical or Health issues *Diabetes, Heart Conditions, Blood Pressure, Surgeries

What services are you interested in accessing? *

PhysiotherapyExercise PhysiologyUpper Limb Exoskeleton/Robotic assisted therapy (elbow and wrist)Lower Limb Single Joint Exoskeleton/Robotic assisted therapy (knee and ankle) Lumbar support exoskeleton (trunk, core and gluteal support)Lower Limb HAL Exoskeleton/RoboFit assisted therapy (walking, sit to standard and balance)Group ClassesI'm not sure yet

Height *Roughly is fine

Weight *Roughly is fine

Shoe Size (US) *Roughly is fine

How do you usually mobilise in the community? (outside of home) *

Walking independentlyWalking with someoneWalking with an aid (e.g., walking stick, walker, frame etc)Independently in a Manual WheelchairIndependently in a Power WheelchairWheelchair propelled by someoneOther:

Please ensure you have your GP fill in our Medical Clearance form before your second appointment to ensure you're able to complete the HAL assessment

Click here to download our Medical Clearance form

Upload your Medical Clearance if it's already completed

Browse

If you have already filled in your medical clearance, please upload here.

Health Team

General Practitioner *

Practice *

Neurologist

Neurologist Practice

Allied Health Professionals - names, Company names and contactsPhysiotherapist, Exercise Physiologist, Occupational Therapist, Speech Pathologist, Dietician, Psychologist, other

Media Consent

As part of our commitment to supporting your progress, we may record your sessions (including video and/or audio) to document your journey. These recordings will be used to track your development, provide visual or auditory feedback, and illustrate your progress at various stages—before, during, and after your sessions. This information will be shared with you throughout your RoboFit Journey to help you see your growth and achievements. We will handle all recordings with care, ensuring they are stored securely and used solely for the purposes outlined above. If you have any questions or concerns about this process, please feel free to discuss them with us.By ticking this box, you agree to allow us to record your sessions for these purposes.

I consent to the use of testimonials, images or videos of myself by RoboFit for promotional use

Consent

I confirm that above information I have provided is true, complete and accurate. *

I consent to my medical data being shared with other members of my medical team for and by Robofit clinicians for appropriate assessment and treatment.

I agree that my medical data can be used for internal research purposes by RoboFit and I am aware that my data will be de-identified, meaning that all personally identifiable information (such as my name, address, or other identifying details) will be removed before it is used in research.

I consent to receiving appointment reminders by email and SMS

Cancellation Policy

We require twenty four (24) working hours' notice for changes and cancellations and reserve the right to charge you the full Price for a Service that is cancelled with less than 24 working hours' notice.

Working Hours include any normal weekday other than a public holiday or office closure between the hours of 9am and 5pm Monday to Friday.

You may cancel a service at anytime by contacting hello@robofit.com.au or calling 1800 560 842.

You agree and acknowledge that this payment is reasonable and a genuine pre-estimate of our loss suffered by reason of the cancellation, given that we would not have been able to allocate alternate work to our Personnel in such a short period of time.

*

Signature *

Draw signature|Type signatureClear

Date *

Name of person signing this form *

I'm a person (who may or may not want to use a robot), and I'm ready to start my Robofit Journey! *

Save and Complete Later