New Patients

Your Name (required)

DOB (required)

Address (required)

Post Code (required)

Email Address (required)

Contact Number (daytime) (required)

Mobile Number

Next of Kin (Name and Contact No (required)

Insurance details if applicable

Policy Number

Authorisation No

GP Name and Surgery (required)

Online Consent

I CONSENT TO A VIRTUAL FIRST APPROACH TO MY PHYSIOTHERAPY CARE DURING COVID-19

YesNo

I CONSENT TO VIDEO/ONLINE CONSULTATION

YesNo

I AGREE TO CHARGES FOR ONLINE CONSULTATION AND WILL MAKE BACS PAYMENT FOR THE SERVICE PROVIDED (UNLESS PRIVATE INSURANCE/MEDICOLEGAL)

YesNo

I CONSENT TO FACE TO FACE TREATMENT AND FULLY UNDERSTAND THE RISKS OUTLINED TO ME BY ANDOVER PHYSIOTHERAPY

YesNo

Please read and sign the declaration below (you can withdraw your CONSENT at any point, Please inform us if you do)

I understand that failure to attend a scheduled appointment will result in a charge equal to the treatment fee, if I fail to give 24 hours notice of cancellation. I understand this charge will be my responsibility as my insurance company will not cover any failure to attend.

YesNo

I hereby give CONSENT for you to securely hold my personal details under new GDPR criteria and duration

YesNo

I hereby give CONSENT (if applicable) for you to share details with other medical professions/insurance companies if my treatment requires it

YesNo

I hereby give CONSENT for you to use my mobile number or email for appointment reminders (if needed)

YesNo

Signed (digital signature) (required)

Date(required)