Medical Insurance Patient Consent Form Please fill out the form below. " Please enable JavaScript in your browser to complete this form.Medical Insurance Patient Consent & Covid 19 FormName *FirstLastDate of Birth(dd/mm/yyyy)AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePreferred Telephone Number *Alternative Telephone NumberEmail *CheckboxesPlease 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 conditionsSteroid TreatmentEpilepsyCancerHeart/chest conditionPacemakerAnti-coagulant TherapyOsteoporosisMajor AllergiesDiabetesAutoimmune DisordersBlood DisordersHave you had any of the above? If Yes, please select.Pre-existing medical conditions - Female Patient OnlyGynaecological 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 problemInsurance Company Details *Insurance Company NameInsurance Company AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryInsurance Company DetailsPolicy or Membership Number *Policy Expiry Date *Authorisation Number *Excess on Policy (£) *Condition authorised for treatment *Payment Method - Please confirm *Medical InsurnanceThat 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 ChecklistYou will needs to select a response for each questionI 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. *YesNoI confirm that if I am unwell, I will inform the clinic and not attend. *YesNoI confirm that if I am unwell, or have been told to self-isolate, I will inform the clinic and will NOT attend. *YesNoI 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. *YesNoI confirm I am aware of the clinic’s requirement for social distancing in the clinic. *YesNoI confirm I am aware of the clinic’s requirement for hand decontamination in the clinic: *YesNoI 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: *YesNoExceptions 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. *YesNoDate *Please check that all your information is correct before submitting.EmailSubmit