Patient Registration Form
Full Name: *
DOB: *
Address *
Preferred contact number (mobile or home) *
GP Practice: *
Which service are you coming to us for: *
Required
It is important that you understand the assessment and treatment you are coming for in order to give your full consent to participate. By signing this form you confirm that you understand the treatment process, understand you may be required to undress and may be physically examined by your therapist. Please be aware that you can change your mind at any time. Your therapist will ensure that you are informed of what is happening over the course of the treatment.
If you have been referred to us by an insurer, GP, solicitor, agency, employer or anybody else that is funding your treatment then it is likely that they wish to know what is found during the assessment and the progress being made with treatment. Please sign below that you are happy for us to share this information. If you require a copy of the report please tick below: *
Required
I have read and understood the provided information booklet and understand what the treatment is likely to involve, the benefits and the potential risks.
Important infomation
If you are attending your appointment in the clinic, because of the risk of coronavirus infection, it is important that we make you aware that there is an increased risk of coronavirus infection if you choose to attend a face to face consultation, despite all precautions being taken by the clinic. If physical treatment is required, the therapist will not be able to follow social distancing rules.
If your session is remote, we do not permit any recording of the session.
By signing this consent for you agree you are aware of the potential risk of attending the clinic, and that remote session recording is not permitted.
Signature *
Date *
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All of your personal records are confidential and we will never share your details with anyone else. The provision of your email address includes reminder emails and any emails we may send containing offers at Joints & Points which we feel may be of use to you. *
Required
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