Title* Forenames* Surname* Home Address* Post Code*
Phone 1* Phone 2 Email Address General Practitioner Age Date of Birth Occupation Leisure Activities Is this your first visit to our Practice? YesNo How did you hear about us? Health Insurance Company Registration Number Authorisation Number
Medical Checklist Please tick if you have a history of the following: Car accidentOsteoporosisHeart problemsWhiplash injuryEpilepsyAllergiesDiabetesCardiac pacemakerBlackoutsCancerBowel or bladder problemsInfectious diseaseDizzinessNausea
Comments on any of the above Please list any x-rays or scans you have had in the last 5 years? Please list details of any other medical conditions you may have Please list all medicines and/or tablets that you are currently taking
From time to time we may want to communicate with you about our products and services. Do you give consent to us to do this via: Email: YesNo Letter: YesNo Telephone: YesNo
As part of your on-going treatment, it may be necessary for us to communicate with other Health Professionals about you and/or your condition. Do you give consent to us to do this? YesNo
From time to time we may want to take the occasional photo/video to be used in Kesson Physio marketing communications. Do you give consent to us to do this? YesNo
Your initial assessment and subsequent treatment sessions will be conducted at Kesson Physiotherapy. Following the initial assessment, a treatment programme will be discussed with you and conducted with your permission. Where applicable (for non NHS, non private medical insurance) the charges for treatment sessions are displayed at our clinic or on our website. All treatment session fees are payable on appointment booking.
*BUPA, AXA PPP has separate contract arrangements with this Clinic
You are kindly requested to check the terms and conditions of your Health Insurance Policy to ensure that Physiotherapy treatment is covered. Kesson Physiotherapy Services cannot be responsible for non-payment of claims.
Cancelled appointments will be accepted with at least 24 hours’ notice. Private patients - A full charge will be made for late cancellations or missed appointments. NHS patients will be discharged back to their GP.
A discharge letter will be sent to your specialist or GP confirming your attendance for treatment together with a summary of your progress – this is subject to your consent and a copy of this letter is available on request.
I consent to the assessment & treatment recommended and performed by Kesson Physio I understand the charges for each course of treatment I understand that I am liable for payment of the treatment fees should my medical insurance company not settle the claim (where applicable) I understand that the information provided on this form will be registered with Kesson Physiotherapy I understand and agree to comply with the cancellation policy I understand that a discharge summary will be sent to my general practitioner and/or specialist if you have my consent to do so and that I may request a copy.
Please sign below to confirm your understanding of the terms and conditions of Kesson Physiotherapy Services. Signature
A copy of our Privacy Policy can be requested at reception or viewed here on our website We use a third party ReviewYoo www.givfb.com to collect our feedback which we may request from you from time to time * Required Fields
01795 534113
contact@kessonphysio.co.uk