NEW CLIENT BOOKING FORM

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 *

Which clinic are you interested in attending? *

Sydney (Mascot)Sydney (Parramatta)North Wollongong (NSW)Brisbane (Shailer Park)

Clinician Preference *

Exercise PhysiologyPhysiotherapyEither

How did you find out about us?

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 *

NISQ Case Number *

Case Manager Name *

Case Manager Email *

Case Manager Phone Number *

We will contact you to discuss the next steps regarding your selected funding type

If you are NDIS funded, we will send through a Service Agreement for completion

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

What are you coming in to see us for? *Diagnosis, Area of weakness/impairment/disability

Reason for Enquiry *

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 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.
We will try to work with you to reschedule your appointment to avoid cancellation fees.
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.

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

Signature *

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Date *

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

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