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Self Funding Patient Consent Form

Book an Appointment
Name
(dd/mm/yyyy)
Address
Email Consent
Payment Method - Please confirm
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

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).

Please check that all your information is correct before submitting.