If you wish to utilise our new video consultation service please fill in the following form and submit it to us so that we can update our records.
Many thanks
Judith
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
I AGREE TO CHARGES FOR ONLINE CONSULTATION AND WILL MAKE BACS PAYMENT FOR THE SERVICE PROVIDED (UNLESS PRIVATE INSURANCE/MEDICOLEGAL)
I CONSENT TO FACE TO FACE TREATMENT AND FULLY UNDERSTAND THE RISKS OUTLINED TO ME BY ANDOVER PHYSIOTHERAPY
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.
I hereby give CONSENT for you to securely hold my personal details under new GDPR criteria and duration
I hereby give CONSENT (if applicable) for you to share details with other medical professions/insurance companies if my treatment requires it
I hereby give CONSENT for you to use my mobile number or email for appointment reminders (if needed)
Signed (digital signature) (required)
Date(required)