Information and Consent Form for  Patients Attending Physiotherapy

Physiotherapy, by its nature, involves close contact between Physiotherapist and patients.   A consultation involves you answering detailed questions about the site, severity, and nature of your complaint, as  well as questions covering how it began, the possible cause, its present 24- hour behavior and any past problems which may be relevant.

A physical examination or assessment will follow, which will involve undressing the relevant area. Appropriate undergarments should be worn, but towels to preserve your modesty are available, so please ask if you feel you require them. You may wish to have a partner or friend with you during the examination and treatment, and this is perfectly acceptable.

The examination is carried out to include unrelated problems and clarify your complaint, so that clinical diagnosis and treatment options can be considered. This may continue each visit, as problems often change in site, irritability, and nature from treatment to treatment. Treatment options will always be discussed with you, as your agreement and co-operation are necessary at each stage.

Although manipulation and examination manoeuvres may be regarded as quite normal by Physiotherapists, if you feel anxious or are concerned about them, please feel  free to  ask for an explanation or to say “stop” if you are  unhappy with anything.

Please wear appropriate attire for your physiotherapy session that is easy for all limbs to move in, such as  shorts and t-shirt.

Chaperone: You have the right to bring someone along with you to your appointment. If you wish to do this, please inform the admin team prior to your appointment, so they can arrange this for you. Under 16’s MUST be accompanied by a responsible adult to their physiotherapy appointment. Please ask your practitioner or reception team always without any hesitation.

As Flex Fast Physio LTD has fully booked clinics, there is a CANCELLATION CHARGE OF UP TO 100% OF THE FEE for appointments that are NOT cancelled or rescheduled with at  least 48 HOURS notice given. If you use private medical insurance, the charge will fall to yourself in accordance with your policy.

If you are using MEDICAL INSURANCE, please ensure that you have your membership number, claim/ authorisation number, details of sessions authorised and any excess on your policy. Please provide this information to our personal assistant or bring them with you to your initial appointment.

If you do not provide us with these details, payment for your treatment will  need to be settle at the end of each session and you will be provide with a receipt to claim back from your insurance company.

Should there be any deficit of payment to us from your insurers and/or you have exceeded your allocated allowance you are  liable for payment of the balance of your account. Please be aware that you may have an “excess” on  your policy which you would also be liable for.

If you are  self-paying for your treatment, payment can be  made by  BACS, card, cash, or cheque which should be completed at the end of each session. Invoices and receipts can be issued on request.

Covid–19

• I have answered all questions relating to my exposure to coronavirus (COVID-19) truthfully.
• I understand that there is a potential risk of transmission of COVID-19 as a result off attending the clinic or having a domiciliary visit and receiving treatment.
• I have had the opportunity to ask all questions I wish to, and all my questions have been answered to my satisfaction.
• I have read, agreed, and understood the statements above relating to the COVID-19) risk and consent to care by Mobility Phsyiotherapy Limited.

By requesting to book an appointment, you confirm the following:

I confirm I have read and understood the content of this consent form

I consent to undertake an assessment and recommended treatment (if applicable)

I consent to Flex Fast Physio Ltd storing my personal and medical information, during my referral period and for as long after discharge, as is required by law

I consent to my physiotherapist sharing my personal data and medical information with my Insurance Company for the purpose of progressing my case (if applicable)

I consent to Flex Fast Physio Ltd sharing relevant personal & medical information with other clinicians, including my GP (if appropriate)

I understand that I am responsible for the cost of my treatment(s) and agree to pay a cancellation fee of 100% if appointments are cancelled within 24 hours of the appointment time, and a full fee for non-attendance of appointments

I understand that I may withdraw my consent at any time, without prejudice