Registration Form
Patient Name ……………………………………
Date of Birth ……………………………………
Address …………………………………………
…………………………………………
…………………………………………
…………………………………………
Email …………………………………………
Consent
I consent to the assessment and treatment recommended by Hart Physio in accordance with the governing body’s professional guidelines. This may include mobilisation, manipulation, manual therapy techniques, soft tissue massage, or electrotherapy modalities. I understand that before any treatment is carried out, a full explanation of the purpose and any risks of that treatment will be provided. I understand that should I wish to decline any form of assessment of treatment, then I am entirely within my right to do so and that I should inform the clinician of my wishes at the time. By signing overleaf I am in agreement with these conditions.
Informing your GP
It is good practice to keep your GP informed of all aspects relating to your health. Please complete the following information if you are happy for us to contact your GP.
GP Name ………………………………..
GP Practice ……………………………..
Your signature ………………………….. Date ………………………………………………………..
Declaration
I understand and accept that it is my responsibility to ensure prompt settlement of the session fees. I understand that any excess payments will need to be paid directly to Hart Physio. Clients who book appointments are required to give 24 hours notice of their inability to attend, otherwise they will be charged in full for the appointment they fail to attend. This policy is deemed necessary to avoid denying appointments to those clients who would have required the space.
Data Protection
All information collected during the course of your assessment and treatment at Hart Physio will remain strictly confidential under the terms of the Data Protection Act.
I have read the Privacy Policy provided and agree to the declaration.
Name ……………………………………………
Signature ……………………………………………. (please note here if you are a guardian)
Date ……………………………………………….
Appointments
Tel 01252 811773
Fax 01252 757909
www.hartphysio.co.uk
info@hartphysio.co.uk
Clinic Clinic Correspondence
Fleet Medical Centre The Court 94 Sandy Lane
Church Road The Elvetham
Fleet GU51 4PE Fleet Road RG27 8AS Hartley Wintney RG27 8DN
Updated April 2018
