Date of Birth
Is this your first visit to our Practice?
How did you hear about us?
Health Insurance Company
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:
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?
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?
Your consultation and treatment will be conducted by a Chartered Physiotherapist. Following the initial assessment, a treatment programme will be discussed with you and conducted with your permission. The charge for treatment sessions is £45 per session. Domiciliary visits may be arranged from £90. The charge for treatment sessions with our junior therapist, Saffron, is £37.00 per session. 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 24 hours’ notice. A full charge will be made for late cancellations or missed appointments.
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 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
I understand 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 tick the box below to create a digital signature that confirms your understanding of the terms and conditions of Kesson Physiotherapy Services.
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