I, the undersigned, understand and agree that: 

1. I have been informed about the nature and purpose of remedial massage therapy/Myotherapy, including the potential benefits and risks associated with the treatment. I understand that remedial massage therapy is not a substitute for medical examination, diagnosis, or treatment, and that it is recommended that I consult with my primary healthcare provider for any medical concerns. 

2. The therapist has explained the procedure to me, and I have had the opportunity to ask questions and receive answers regarding the treatment. I understand that I can withdraw my consent and discontinue treatment at any time. 

3. I am financially responsible for all charges related to the services provided to me by NerveSync Pty Ltd | Perth Migraine Centre, regardless of my private health insurance status. 

4. I will pay the amount in full at the time of service. 

   
   

Co-Payments and Gap Payments: 

I understand that any co-payments, gap payments, or non-covered services are due at the time of service, unless otherwise negotiated. 

Payment Options: 

I understand that NerveSync Pty Ltd | Perth Migraine Centre provides several payment options and that it is my responsibility to discuss these options if I have financial concerns. 

Non-Payment:

I understand that if my account becomes overdue, I may be charged collection fees, and/or legal fees incurred to collect the balance. I also understand that NerveSync Pty Ltd | Perth Migraine Centre may refuse future services due to non-payment. 

Cancellation Policy: 

I acknowledge that NerveSync Pty Ltd | Perth Migraine Centre has a 2 working days cancellation policy. If I do not cancel my appointment within this time frame, I may be charged a cancellation fee. 

Acknowledgment and Consent: 

By signing below, I acknowledge that I have read, understand, and agree to the terms of this Patient Financial Consent Form. A Guardian should be signing on behalf of the patient if the patient is less than 18 years of age or is medically unfit to give consent.