Our patient agreement

REGISTRATION AND CONSENT FORM

Please read and submit the registration and consent form below before your appointment. Note that this is our patient agreement with you so you should read through carefully to make sure you’re happy to proceed. By submitting this form you are agreeing to the terms and conditions set by Body Logic.

Your appointment is not confirmed until you have received confirmation via email.

Personal details

Name(Required)

First Last

Date of birth(Required)

Address(Required)

Street Town/City Postcode

Email(Required)

Mobile phone number(Required)

Altenative phone number

GP's surgery name(Required)

Health insurance

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 policy number and authorisation number

If you are a BUPA patient, please ensure you have your authorisation code and that you know whether the code is for standard physiotherapy OR shockwave therapy. Please confirm which by ticking the appropriate box below.(Required)

Standard physiotherapy

Shockwave therapy

Not using BUPA

If you are NOT a BUPA patient, please tick "Not using BUPA"

Medical conditions

Do you have any of the following medical conditions? (Please select yes or no)

Asthma(Required)

Cancer(Required)

Diabetes(Required)

Difficulty swallowing(Required)

Epilepsy(Required)

Heart conditions(Required)

High blood pressure(Required)

Loss of smell and/or taste(Required)

Loss of vision(Required)

Night sweats(Required)

Osteoporosis(Required)

Pregnancy(Required)

Regular fainting(Required)

Speech problems(Required)

Unexplained weight loss(Required)

Other medical information

Details of surgery or other illnesses(Required)

What medications are you taking?(Required)

Consent

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.(Required)

I understand

Occasionally (a handful of times a year only) we may share special offers, important clinic updates and information that may be of interest to you (We will never spam you!)(Required)

That's fine

No thanks

How did you hear about Body Logic? (please select and thank you for your assistance)(Required)

Comments

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