This questionnaire is for your safety, as well as our information. If you have any questions, please ask your physiotherapist. Thank you for your co-operation. Block capitals please
Full name:______________________________________________________________________________________________________
Full address:_________________________________________________________________________________________________________________________________________________________
Post Code: _____________________________________________________Date of Birth: ___________________________________________
Home tel No: ___________________________________________ Work tel No: ____________________________________________
Mobile No: ______________________ Email: __________________
Have you ever visited this practice before? If yes, when?_____________________________________________________
Your occupation: _____________________________________________________Hobbies:_______________________________________________
Name and Address of GP: ___________________________________
_____________________________________________________
Who recommended Kingsmead to you?__________________________________________________________________________________________________________
To opt out of text reminders please tick: _____
How do you wish to pay for your treatment?
Self Funding/Medical Insurance
If medical insurance please complete the following:
Name of insurer___________________ Membership No________________________Auth No_____________________
Please note payment will be expected at every treatment or at the end of every month
Medical checklist:
Have you had any operations? If yes, please give details:_____________________________________________________________________________________________________
Have you had any of the following? If yes, please tick.
Headaches Cancer Osteoporosis
Heart condition Car accident Bladder problems
Epilepsy Other accidents Spinal fractures
Pacemaker Skin conditions HRT
Anti-coagulant therapy Gynaecological Conditions
Other Fractures Do you smoke?
Are you currently seeing your doctor for any other condition? If yes please give details:__________________________________________________________________________________________________________________________________________________________
Height: ________________Weight: _________________________
What medication are you currently taking?_______________________
PLEASE NOTE THAT UNLESS 24 HOURS NOTICE IS GIVEN TO CANCEL AN APPOINTMENT WE REGRET TO ADVISE THAT THE FULL FEE WILLBE CHARGEABLE
I consent to treatment at Kingsmead Physiotherapy Clinic Ltd.
I understand that my GP may be informed of my attendance and progress unless I request otherwise.
I understand that the clinic will retain records relating to my treatment in line with General Data Protection Regulation (2018) and I hereby undertake to pay Kingsmead Physiotherapy Clinic Ltd for treatment as a private patient including any circumstances where medical insurance or third party proves not to cover the specific course of treatment.
Signature………………………………………. Print……………………………………………… Date……………………………………………
If filling in this form on behalf of a patient:
Name: ………………………………. Relationship to patient: ……………………………….
Reason for filling in form on their behalf: ……………………………………………………
Kingsmead Physiotherapy Clinic, 224 Pollards Oak Road, Hurst Green, Oxted, Surrey RH8 0JP
Tel & Fax: 01883 712987 mail@kingsmeadphysio.co.uk www.kingsmeadphysio.co.uk
