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Registration Form

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

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