Medical Insurance Patient Remote Consent Form | Ashbourne & Hilton Physiotherapy & Sports Injury Centre

Name *

First

Last

Date of Birth

(dd/mm/yyyy)

Address *

Address Line 1

City

State / Province / Region

Postal Code

Preferred Telephone Number *

Alternative Telephone Number

Email *

Checkboxes

Please tick if you agree to us contacting you with service updates, information & newsletters & discount codes. We will not share with 3rd parties.

G P Practice *

Medical Checklist.

We ask these questions for your safety. Please contact us or ask at your appointment if you have any queries or are uncertain.

Pre-existing medical conditions

Have you had any of the above? If Yes, please select.

Pre-existing medical conditions - Female Patient Only

Gynaecological Conditions?
HRT?
Are you Pregnant?

Are you currently seeing your Doctor for any other conditions? If yes please give details:

What medication are you currently taking?

Please tell us about any recent operations or past operations that might affect your current problem

Insurance Company Details *

Insurance Company Name

Insurance Company Address

Address Line 1

City

State / Province / Region

Postal Code

Insurance Company Details

Policy or Membership Number *

Policy Expiry Date *

Authorisation Number *

Excess on Policy (£) *

Condition authorised for treatment *

Payment Method - Please confirm *

Medical Insurnance

That the details I have supplied are current and correct for this course of treatment. I understand that I may be charged for missed appointments or appointments cancelled at late notice (less than 24 hours) I understand that the clinic will need to correspond with my insurance company about my course of treatment.

Date *

Please check that all your information is correct before submitting.