Please read carefully, complete your details and confirm your consent to register.
Note: An appointment is not confirmed until you have received confirmation via text message.
Your Full Name
Date of Birth
Mobile Telephone Number (we will use this to confirm your appointment)
Alternative Contact Number
Name of your GP
GP Surgery Name
You are liable for ANY outstanding sums unpaid by your insurer/referrer. With all insurance clients YOU the patient are responsible for informing Body Logic of the number of sessions authorised by your insurer NOT Body Logic. Body Logic does not liaise with your insurer on this matter. If you come for a session YOU must be certain that your insurer will pay.
By completing the below insurance details, you consent to the above.
Health Insurance Provider (if applicable)
Health Insurance Policy Number (if applicable)
Please indicate with a tick if you have or have had problems with the following:
AsthmaBlood pressureCancerDiabetesDizzinessEpilepsyFaintingHeartNight sweatsOsteoporosisPregnancySmellSpeechSwallowingVisionWeight lossNone of the above
Details of surgery or other illnesses
What medications are you taking?
Examination is the assessment of movement, body position, specific body structures and the way these interrelate. This often involves clothing being removed and the physiotherapist using his/her hands to palpate (assess by feel) areas of possible involvement with your problem. If you have any reservations about this please discuss them with the physio before your treatment begins.
After your examination, the findings will be discussed with you and a treatment plan established. You are urged to ask about anything you do not understand, and to have your say in determining the way forward. Treatment may include manual techniques, stretching, massage, exercises, electrotherapy (eg ultrasound), heat or cold and a home program.
Occasionally we send out information regarding our services. May we contact you? Yes, that's fineNo thanks
How did you hear about Body Logic? (please tick and thank you for your assistance)
Insurance companyInternet searchRecommended by a consultant/GP/other health professionalRecommended by a friendSocial mediaWalk byWord of mouthOther
I have read the information above and consent to examination and treatment following discussion of what is involved with the treating physiotherapist (parents or guardians of minors please print name on their behalf). If you are unable to attend an appointment please advise as soon as possible. Failure to cancel an appointment with less than 24 hours notice will incur the full appointment fee and we reserve the right to discharge repeat offenders. As clinicians have a legal duty to store your data & our Privacy Notice is available for you to read here.
Comments are closed.