Registration Form - Premium Physio

Patient Intake Form (#3)

PERSONAL INFORMATION

First Name

Last Name

Phone no.

Date of Birth (Please click on year to reveal a list of years)

Address

Address Line 1

Address Line 2

City

County

Post Code

Country

HOW DID YOU HEAR ABOUT US

GP DETAILS

GP Name (If Known)

Name of GP Surgery / Practice

Address Line 1

Address Line 2

City

County

Post Code

Country

Do you suffer or have you had any other medical condition

Yes

If yes, please specify

Are you on any medication?

Yes

If yes, please specify

I confirm that Premier Therapy can provide a medical report if requested to do so by my insurer or third party

Yes

I confirm that Premier Therapy can contact or write to my GP or Specialist concerning my treatment

Yes

METHOD OF PAYMENT

Method of payment

Self-funding

Insurance

If 'other', please specify

Policy Number

Authorisation / Claim Number

Number of session authorised

Excess on policy

FINANCIAL CONSENT

PLEASE READ AND SIGN BELOW

In consideration for the consultation and treatment received I accept full financial liability for all the services performed and items supplied, regardless if I have health insurance. I understand and agree to the payment criteria as detailed overleaf and that the company will exercise their statutory right to claim interest (at 8% over the Bank of England base rate) and compensation for debt recovery costs.

CANCELLATIONS OF APPOINTMENTS. A cancellation fee for the full treatment will be charged if you fail to give 24 hours notice that you will not be attending an appointment.

PAYMENT. Payment for treatment is due at the end of each session. Payment can be made by credit card, debit card or BACS transfer.

PRIVATE HEALTH INSURANCE. We can submit your invoices directly to your insurer for settlement if the all insurance details are provided prior to your first treatment. If this information is not available you will be required to pay for your treatment at the end of each session until such a time it is made available. We will make every effort to ensure that your account is processed by your insurer, however it is the responsibility of the patient to ensure that their claim meets all the necessary criteria set down in their policy document. We respectfully remind patients that if your insurance company does not settle your full claim promptly or there is a shortfall then the liability falls to the patient to settle the account directly when requested to do. Failure to do so may involve us reluctantly instructing a debt collection agency.

First Name

Last Name

Initial to sign

PLEASE READ AND SIGN BELOW

CHAPERONE: You are more than welcome to bring a chaperone, or family member / friend to accompany you during your treatment.

I confirm that the information given on this form is to the best of my knowledge true and correct and if any of the details change I will immediately inform a representative of the company.

I have read the terms and conditions set out above and agree to abide by them. I confirm that I give consent for an examination and any treatment (including, but not limited to, acupuncture, manipulation & joint injection), which may sometimes cause some bruising, soreness or pain afterwards.

I confirm that I may have an ultrasound scan from time to time. I acknowledge this is not reliably diagnostic and may be used as part of my overall assessment and physical examination. I confirm a report is not necessary and confirm no images will be stored or saved for your confidentiality but you may take photos of the scan if you wish.

I understand that I can withdraw from the treatment at any time, and will ask the practitioner, if I have any questions or concerns related to my treatment

First Name

Last Name

Initial to sign