If I am unable to attend my appointment, I will give at least 12 hours notice of my cancellation. Payment is due at the time of consultation. I understand that if my account is overdue, I will be invoiced accordingly. Any accounts which are not settled by the end of the month will incur an additional administration fee of $10 for every month overdue. Any outstanding accounts requiring us to use a recovery agent will incur further additional processing charges. To claim through workers compensation, we will need your employer’s details, insurance details, case manager and claim number (please see above). Any missed appointment/s without cancelling may incur a fee equivalent of 50% of the consult cost. Any information on this form will not be disclosed to any other parties.