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

Medical Insurance Patient Consent & Covid 19 Form

Name *

First

Last

Date of Birth

(dd/mm/yyyy)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Preferred Telephone Number *

Alternative Telephone Number

Email *

Email Consent *

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

Address Line 2

City

State / Province / Region

Postal Code

Country

Insurance Company Details

Policy or Membership Number *

Policy Expiry Date *

Authorisation Number *

Excess on Policy (£) *

Condition authorised for treatment *

Medical Insurance Declaration & Financial Responsibility (Please confirm) *

I confirm 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.

GDPR Privacy Notice (Please confirm) *

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.

Medical Declaration & Consent (Please confirm) *

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 any 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).

Patient Signature *

Clear Signature

Signature of person with parental responsibility or the person legally entitled to sign on behalf of a person who lacks capacity

Date *

Please check that all your information is correct before submitting.