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Medical Insurance Patient Consent Form

Please fill out the form below.

 

Medical Insurance Patient Consent & Covid 19 Form
(dd/mm/yyyy)
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.
Have you had any of the above? If Yes, please select.
Insurance Company Name
Insurance Company Details
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.

I understand that I am ultimately liable for treatment costs should my insurance not make timely payment. I understand that I am liable for any excess payments on my policy. I understand that payment can only be obtained from my insurance company if I have supplied all the necessary information. If I am unable to supply this at the time of my appointment, I confirm that I will pay and will be issued with a receipt so I may reclaim my costs from my insurance company.

I confirm that I am aware that there is a GDPR Privacy Notice available to access either from the link above or on the website (www.ashbournephysio.co.uk) and consent to Ashbourne & Hilton Physio Centres holding & processing my personal data as outlined. I understand that I may withdraw my consent in writing at anytime but recognise the clinic has legal & contractual obligations to adhere to. I understand it is my responsibility to inform the clinic of any changes in my details.

I confirm that the information given is accurate and I consent to physiotherapy, noting that my therapist is likely to need to see and touch the injured part of my body. I am aware I can retract my consent at ony point and I will immediately inform the therapist if at any stage I have concerns or reservations about the treatment proposed or if I would like to request a chaperone (Notice maybe required for a chaperone).

Clear Signature
Signature of person with parental responsibility or the person legally entitled to sign on behalf of a person who lacks capacity
Please check that all your information is correct before submitting.