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.

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

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, 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

Covid - 19 Checklist

Date *

Please check that all your information is correct before submitting.