Registration and Consent Form for Treatment

Registration and Consent Form for Virtual and Clinic based treatment

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 Details

Your Full Name

Date of Birth

Address

Postcode

Email

Mobile Telephone Number (we will use this to confirm your appointment)

Alternative Contact Number

Name of your GP

GP Surgery Name

Health Insurer Details (if applicable)

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)

Medical Conditions

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?

Physiotherapy examination and treatment (with some exceptions re virtual physiotherapy)

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

Consent and General Data Protection Regulation (this our agreement with you)

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.