Patient Consent & Treatment Authority Form

Patient Consent Form

Please fill out the form below as accurately as possible and read the terms & conditions prior to submitting your information to share your consent with us and provide information about yourself for our practitioners to ensure we are able to provide the most appropriate care for you and your condition. 

Are you in any high-risk medical category?

Declaration of Consent

Terms and Conditions 

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. 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.

Clothing: To ensure an accurate assessment, it may also be necessary to remove certain of articles of clothing. Please bring suitable clothing, for example, singlet top or shorts for your assessment.

Treatment: 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, Specialist Physiotherapy Ltd performs periodic clinical audits to ensure compliance with our strict record-keeping protocols. By signing this form you are acknowledging that your notes may be randomly selected as part of the audit quality review 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.

Your declaration and signature

By submitting the form you confirm the following:

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 Specialist 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 Specialist 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