Consent Form

Thank you for making your booking at de Leon Physio and we look forward to meeting you. Please ensure that you have read, completed and signed this form prior to your first appointment.

Consent Form

First Name

Last Name

Mobile Number

Address

Address Line 1

Address Line 2

City

Postcode

Country

Date of Birth

Please select payment type/cover

Insurance Company and Policy/membership no:

Authorisation/claim no:

Terms and Conditions

Private Medical Insurance Claims
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Please be aware that any non-payment by your insurance companies or excesses are your responsibility and will be invoiced to you. Payment will be expected within two weeks. Please be aware of your policy limitations and keep track of your allowance. Any appointments you undertake prior to advising de Leon Physio of your wish to use your insurance company or obtaining your insurance companies approval will be charged to you at the full rate and will not be refundable. If you are not claiming with private medical insurance, you will be expected to settle all amounts within 2 weeks of receiving the invoice.

Cancellation Policy
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If you fail to attend a treatment or class, or reschedule or cancel with less than 24 hours notice, you will be obliged to pay for the full cost of the missed session. Please note that insurance companies will not pay for missed or rescheduled appointments where the required notice is not given.

Consent to treatment
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On your first visit, a detailed case history including a full medical history and physical examination will be taken. The therapist may ask you to remove an item/s of clothing to assess the affected body part. Therefore, please wear something that you will feel comfortable in. For a lower limb injury, it would be helpful if you could bring or wear shorts and your running/training shoes and any orthotics you may have. Prior to commencing treatment, your physio will discuss the problem with you and explain the reason behind the chosen treatment modalities. These may include joint mobilisation or manipulation, soft tissue massage, acupuncture and exercise prescription. Of course, no treatment will be carried out without your verbal consent at the time. However, you are required to sign this form consenting to the whole assessment and treatment process.

Please find our privacy and use of data policy here http://deleonphysio.co.uk/privacy-policy/

By ticking this box and signing below, I warrant that I have read and fully understand the terms and conditions, and the privacy policy, and I give your consent for treatment and agree to adhere to the requirements for treatment. I also consent for my information to be stored.

Signature

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