Full Name (required)
Your Email (required)
Date of Birth (required)
Contact Number (required)
Insurance Company (required)
Policy Number (required)
Authorisation Code (required)
Number of Treatments (if known)
In order to safeguard patients and staff, The Physiotherapy Clinics and Peebles Physiotherapy have put in place strict infection control measures and protocols at all of their clinics. This includes the use of Personal Protective Equipment and the cleaning of equipment and treatment facilities prior to your appointment.
I am not in any high-risk medical category, including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy.
If incorrect, please provide details of medical condition(s):
I understand that due to the frequency of visits of other patients, the characteristics of covid-19, and the characteristics of physiotherapy treatment, that I have an elevated risk of contracting the virus simply by being in the clinic.
Should I develop any symptoms prior to any of my appointment(s), including a prolonged cough, fever, or shortness of breath, or have been in contact with anyone with similar symptoms or confirmed to have contracted Covid-19, I agree to not attend my appointment and notify The Physiotherapy Clinics and Peebles Physiotherapy by email: firstname.lastname@example.org or call 07738 304238.
I agree to follow the instructions provided by the clinic staff in order to reduce the risk of spreading the virus. This includes my wearing a new mask which will be provided by the clinic at the time of my appointment.
Privacy Notice: We take your privacy very seriously and will take all necessary steps to protect your data and sensitive information. We comply with the Data Protection Act 1998 and all relevant medical confidentiality guidelines. Your confidential medical information will only be disclosed to those involved with your treatment. Further details can be found on our website.
Assessment: Your assessment will be carried out by a qualified and experienced Physiotherapist who will explain the process to you. During the assessment, the Physiotherapist will ask relevant questions about your injury and symptoms. There will also be a physical assessment, which may include various tests including hands-on palpation. To ensure an accurate assessment, it may also be necessary to remove certain of articles of clothing. Sometimes you may experience discomfort during the examination, and this should be reported to your Physiotherapist. You will not be asked to perform any task which is not relevant to your injury/condition. It is not unusual to experience some mild aggravation of symptoms after assessment, due to the need to try to reproduce your symptoms so that the Physiotherapist can form a valid clinical impression and formulate a treatment plan.
Treatment (If applicable): Following your assessment, your Physiotherapist will discuss a treatment plan and expected outcomes with you. Treatment may include self-management strategies and exercises for you to do at home. Other physical treatments may or may not make up part of your treatment, as deemed appropriate by your Physiotherapist. It is not unusual to experience discomfort or, with some treatments, superficial bruising afterward. You may be asked to sign an additional form for certain treatments, stating that the Physiotherapist has explained the treatment and cleared any health-related risks with you.
Clinical Audit: To ensure that the highest possible standards of patient and clinical care are being delivered, Peebles Physiotherapy Ltd and your insurance company perform periodic clinical audits to ensure compliance with strict record-keeping protocols. By signing this form you are acknowledging that your notes may be selected as part of the audit quality review process. Your notes will not be copied, removed or used for any other purpose.
Complaints: In the event a complaint is received by your insurance company or to ourselves, it may be necessary to review your clinical notes as part of the investigation process. Your notes will not be copied, removed or used for any other purpose.
Please ask your Physiotherapist if you have any questions about your assessment or treatment. It is also your right to request copies of your notes or any information sent to your insurance company.
Your declaration and signature
By submitting this form you confirm the following:
I confirm I understand that face to face physiotherapy appointments increase the risks of contracting Covid-19
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 Peebles Physiotherapy 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 Peebles Physiotherapy 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 50% 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
What made you decide to use us (optional)?
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Terms & Conditions
Peebles Physiotherapy Ltd
1 Old Tweeddale Garage
Tel: 0131 218 3000