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NHS Funded Patient Consent Form

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NHS Patient Consent & Covid 19 Form
Name
(dd/mm/yyyy)
Address
Email Consent
NHS Referral
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.
Female Patient Only

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 / 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.