Patient Registration

Title (Mr/Mrs/Miss/Ms) (required)

Full Name (required)

Date of Birth (required)

Full Address (required)

Your Email (required)

Telephone (Home) (required)

Mobile Number

Occupation

Your GP’s Name

Doctors Address

Health Insurance Name & Number (if applicable)

How did You hear about this clinic?

You are required to provide consent for various aspects of treatment, data protection and charges within the practice. Please read and sign all RELEVANT sections within the consent form prior to your appointment.

CONSENT TO TREATMENT
I consent to treatment and rehabilitation at Bodysym Physiotherapy and Injury Management. In doing so, I understand, acknowledge and affirm that such treatment will involve physical contact and manual techniques that may cause temporary discomfort in the pursuit of improved health.
YesNo

TREATMENT OF MINORS
I, as parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises and chaperone the minor during any such treatment and waive any claim I may have resulting in failure to do so.
YesNo

AUTHORISATION OF PAYMENT
I hereby agree to pay in full for any treatment/services and products I may receive through Bodysym Physiotherapy and Injury Management. I understand fully that in the event my insurance company or financially responsible party does NOT pay for the services/products I receive, I will be financially responsible for payment.
YesNo

NON-ATTENDANCE POLICY
I understand that failure to attend an arranged appointment at Bodysym or failure to give adequate notice of a non-attendance (4 hours prior to treatment time) MAY result in being responsible for a late cancellation fee or full consultation charge at the discretion of the treating clinician.
YesNo

CONSENT TO RETAIN PERSONAL INFORMATION
Bodysym holds your personal details for several reasons including, being a legal requirement for treatment, appointment reminders, contacting you, or your consultant/GP for clinical reasons, sending exercise programmes and occasionally marketing and clinic news or news of new services. We DO NOT share your details with other agencies.
YesNo

I am happy for Bodysym to retain my personal data for legal and clinical purposes
YesNo

I would be happy for you to contact me via email and SMS for clinical reasons
YesNo

I would be happy for you to contact me for clinic marketing and news
YesNo

RELEASING OF MEDICAL DATA
I authorise the release of relevant medical information relating to my current condition such as diagnostic reports, scans, tests etc between clinical staff within the clinic and other external medical parties such as GP’s and Specialists when this is deemed necessary by myself and the treating clinician. I understand that Bodysym are acting in my best interests and that all other medical information will remain completely confidential.
YesNo

I hereby confirm that I have read, understood and accept the above terms and conditions outlined in this document

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