Self Funding Patient Remote 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.

G P Practice *

Payment Method - Please confirm *

Self Funding

I understand that payment is expected prior to 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

Date *

Please check that all your information is correct before submitting.