Self Funding Patient Consent Form - Ashbourne & Hilton Physiotherapy & Sports Injury Centre

Name *

First

Last

Date of Birth *

(dd/mm/yyyy)

Address *

Address Line 1

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.
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.

GP Practice *

Payment Method - Please confirm *

Self Funding

I understand that payment is expected at each treatment. I understand that I may be charged for missed appointments or appointments cancelled at late notice (less than 24 hours)

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

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

I confirm that I am aware that there is a GDPR Privacy Notice available to access 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).

Signed Patient *

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.