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Medical Insurance Patient Consent Form

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Medical Insurance Patient Consent & Covid 19 Form
Name
(dd/mm/yyyy)
Address
Email Consent
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
Insurance Company Name
Insurance Company Address
Insurance Company Details
Medical Insurance Declaration & Financial Responsibility (Please confirm)
GDPR Privacy Notice (Please confirm)
Medical Declaration & Consent (Please confirm)
Clear Signature
Signature of person with parental responsibility or the person legally entitled to sign on behalf of a person who lacks capacity

Please note that your are welcome to be accompanied during your treatment and that all under 16 year olds must be accompanied.

16-18 year olds must be accompanies to the clinic for their first appointment.

For further information on each of our therapists, the conditions we treat and other services we provide, please see our websites:

www.ashbournephysio.co.uk www.hiltonphysio.co.uk

Please check that all your information is correct before submitting.

Write Your Review

We’re so sorry to hear that you aren’t happy with our service. Your feedback is really important to us and we do all we can to make sure we are constantly improving. Please leave your feedback for us below and we’ll get back to you to see what we can do to resolve any issues you may have.

Write Your Review

We’re so sorry to hear that you aren’t happy with our service. Your feedback is really important to us and we do all we can to make sure we are constantly improving. Please leave your feedback for us below and we’ll get back to you to see what we can do to resolve any issues you may have.

Write Your Review

We’re so sorry to hear that you aren’t happy with our service. Your feedback is really important to us and we do all we can to make sure we are constantly improving. Please leave your feedback for us below and we’ll get back to you to see what we can do to resolve any issues you may have.