Consent To Physiotherapy Treatment Title MrMrsMissMasterMsSirDr Patient Name DOB Address Post Code Work Tel Home Tel Mob Number E-mail GP Name GP Address Occupation How were you referred? GP, Employer, Family, other? The nature of therapy is such that close body contact and touching will probably form part of your treatment. You will be required to remove items of clothing. Physiotherapy treatment may consist of manual therapies, electro therapies, exercise therapies and allied procedures. Your therapist will discuss treatment options including benefits and significant side effects. Patients may experience slight soreness following treatment - this is perfectly normal. All patients are entitled to be chaperoned during their treatment if they so wish. Please make this clear prior to commencing treatment. I wish to be accompanied during my treatment YesNo I understand that a remote / virtual consultation will only be recorded at my request YesNo Following an examination and assessment, a treatment programme if appropriate will be explained to me. CLINIC FEES: Physiotherapy First consultation (virtual or in clinic) £48.00 Physiotherapy Subsequent treatment £45.00 Domiciliary visit £85.00 I ACCEPT A CANCELLATION CHARGE WILL BE IMPOSED IF LESS THAN 24 HRS NOTICE IS GIVEN. THIS WILL BE THE FULL TREATMENT FEE. I understand that my GP/consultant will be informed of my attendance and progress, unless I request otherwise Statement of consent I confirm I have read, understood, and have had the opportunity to ask questions related to the information on this form Signed Date Private Health Insurance Private Health Provider Member No Claim/Auth No Please state excess or limitations on policy: Excess £ Limitation £ I understand that I am liable for any excess/limitations/or lapsed policies not accepted by the insurers. Those patients whose health insurance policies require re-authorisation (by insurers/GP/Consultants) must provide this in writing prior to commencement of physiotherapy treatment.
