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 *

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

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 *

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 *

Covid - 19 Checklist

You will needs to select a response for each question

I confirm that I have not had any cold or flu symptons, temperature or a loss of sense of taste or smell in the 10 days prior to my appointment. *

Yes
No

I confirm that if I am unwell, I will inform the clinic and not attend. *

Yes
No

I confirm that if I am unwell, or have been told to self-isolate, I will inform the clinic and will NOT attend. *

Yes
No

I confirm that to the best of my knowledge, I have not been in close contact with anyone with confirmed COVID-19 in the last 10 days and have not had a positive Covid test in that time. *

Yes
No

I confirm I am aware of the clinic’s requirement for social distancing in the clinic. *

Yes
No

I confirm I am aware of the clinic’s requirement for hand decontamination in the clinic: *

Yes
No

I confirm I am aware that I am expected to wear a face covering while at the clinic in line with Public Health England guidance for Healthcare Providers¹: *

Yes
No

Exceptions to wearing face mask may apply.

I understand that my therapist is required to wear PPE as set by Public Health authorities during my appointment. *

Yes
No

Date *

Please check that all your information is correct before submitting.