Physiotherapy treatment information and patient consent for treatment

You have the right to be accompanied by a chaperone/friend or relative as long as you provide consent.

You will be asked for your full medical history before the Physiotherapist will carry out the physical assessment and treatment. Please give an accurate medical history. This will ensure that appropriate treatment can be given.

The Physiotherapist will discuss their findings and inform you of the treatment option before starting. If anything is unclear or you feel uncomfortable about any aspect of the treatment, please let the Physiotherapist know before starting.

During the treatment, you may ask questions about your treatment and express any concerns. You may also withdraw consent at any time during the treatment. Physiotherapy treatment can include the following:

Joint manipulations.
Joint mobilisations.
Muscle soft tissue work or deeper trigger point release (using various massage techniques).
Dry Needling - using acupuncture needles to stimulate the body's healing response. This is not the same as Traditional Chinese Acupuncture. With Dry Needling technique, the needles are only placed into the affected muscle orjoint and are in place for a short time.

Your appointment is for approximately 30 minutes.

Please note that Physiotherapy treatment can result in a slight increase in pain for 12-24 hours following treatment.

Full Name

Date *

Date of birth *

Address *

City

Postal Code

Phone *

Email *

Height *

Weight *

For future appointments and administration, our preferred communication route/s is:

Other (please state)

Is your booking covered by AXA or BUPA insurance?

The Physio Central CLINIC

General Data Protection Regulation 2018

Explicit Consent

I explicitly consent to you creating and storing medical records concerning my treatment, which may include details concerning my medication, treatment and other issues affecting my health conditions, in accordance with the General Data Protection Regulation (GDPR). I understand that these records will be retained for eight years, (or until I reach 25 in the case of someone aged 16 - 18), when treatment is ceased in order to comply with the Chartered Society of Physiotherapy legal guidelines. I understand that these records will be processed in accordance with your 2018 Privacy Notice, a copy of which I have seen.

I have read and understood the above information and give my explicit consent:

If acting in the capacity of a legal guardian, please state your role and authority

Promotional Information

For the purposes of promoting healthcare including offers and advice the Practice would also like to stay in touch with you, with information that may be of interest to you.

For providing promotional information, if you don't want to be contacted by any method, please de-select the following: *

Phone

Post

48 hour notice Is needed if you wish to change or cancel your future appointment. Otherwise, you will be asked to pay for the missed appointment.

Please note that if you arrive late, your treatment time may be reduced.

I have read and understood the above information.

Signature: *

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