Physio Effect Registration and Treatment Consent Form
Email address *
Please complete the questions below
Title
Your answer
First Name *
Your answer
Last Name *
Your answer
Date of birth: DD/MM/YYYY (please use exactly this format including '/') *
Your answer
Gender
Phone Number *
Your answer
Address 1
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Address 2
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Address 3
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City
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Postcode
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How did you hear about us?
Please let us know who referred you (if relevant)
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Occupation
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Emergency Contact Name and Phone Number
Your answer
Private Medical Insurance Details (if applicable):
please select your provider from the dropdown list below
Insurance Provider (please note there is a supplement to pay with some providers - https://physioeffect.co.uk/private-medical-insurance/):
If you answered "Other" above, please detail
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Membership Number:
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Authorisation Code:
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Allowance for this injury/ issue (eg Initial appointment plus 4 returns):
Your answer
Do you have any excess on your Policy? (please check your policy) If yes, please state amount
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Medical Information
Do you have any of the following or any other condition that the practitioner should be made aware of?:
Other (please state):
Your answer
Are you currently on any medication? : (please specify below if yes)
Your answer
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