Patient Details and Online Consent Form

oxonphysiotherapy@outlook.com

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City County Post Code Country

Contact Number(Required)

Email(Required)

GP and GP Surgery(Required)

Next of Kin(Required)

Next of Kin contact Number(Required)

Consent Declaration(Required)

I, the client, consent to the assessment and treatment by the Physiotherapist at OXON Physiotherapy. I understand that before any treatment is carried out, a full explanation of the purpose and any risks associated with the treatment will be explained to me. I understand that should I wish to decline any form of assessment or treatment, then I am within my right to do so and I should inform the Physiotherapist of my wishes at the time.

We sometimes contact clients’ GP/ consultant in order to feedback on aspects of the client’ assessment and treatment in order to maximise their treatment or guide future treatment/investigations.
Please indicate by ticking the appropriate box whether you consent for us to do this.

I consent for OXON Physiotherapy to contact my GP/Consultant with treatment reports.

By signing below, I agree to these terms.

Signature(Required)

Date(Required)

Please confirm if you are an insurance client(Required)

Yes

No

I consent to the physiotherapist sending a report of their assessment findings to the relevant insurance provider at the beginning and end of treatment when required.

Yes I consent

Insurance Company

Membership Number:

Authorisation Number: