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Physiotherapy Patient Onboarding Form
In order for us to help you best, please could you complete
this short form. All information is kept
completely confidential. Many thanks Jo & Team.
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* Indicates required question
Email
*
Your email
Your name and relationship to child
*
Your answer
Your mobile phone number
*
Your answer
I have parental responsibility for the child:
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Yes
No
First Name (of child)
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Your answer
Last Name (of child)
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Your answer
Preferred Name (if different) and Pronouns
Your answer
Address (inc. post code)
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Your answer
Date of Birth (of child)
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MM
/
DD
/
YYYY
Current School Year
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Your answer
GP Name and Phone / Email
Your answer
It would be really helpful to know a little about who lives at home
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Your answer
Does your child have a particular need or diagnosis?
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Your answer
Please list any significant medical investigations or treatment your child has had or is currently waiting for e.g. surgery, lengthy hospital stays, MRIs etc
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Your answer
Does your child take any regular medication?
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Your answer
Does your child have any allergies or a history of seizure activity? If so, please include seizure and allergy action / management plans here
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Your answer
Child's school, nursery or education arrangements:
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Your answer
Does your child have an EHCP and when is their annual review?
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Your answer
Can you tell us about what you need help with or what your concerns are at the moment?
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Your answer
Other professional involvement (OT, SLT, Paediatrician etc) - Who? Where do they see your child? How often?
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Your answer
Are you happy to receive news and special promotions by email?
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Yes
No
I certify that the above information is correct to my knowledge.
*
Yes
No
Required
How did you hear about us?
Friend
Physician / Specialist
Online Ad
Web Search
Other:
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I authorise the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorise the clinic and its associated health professionals to communicate with my GP and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
*
Yes
No
Cancellation Policy. Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the practitioners day that could have been filled by another client. As such we require 48 hours notice for any cancellations or changes to your appointments. Clients who provide less than 48 hours notice or miss their appointment will be charged.
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I am aware of and agree to the cancellation policy.
Consent to taking and storing of photos and videos:
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I agree to photos and videos being taken of my child during their sessions in order to record progress.
I consent to photos and videos of my child being shared for marketing and publicity purposes on social media platforms such as Facebook and Instagram. I understand that no personal details such as my child's name and medical history will be shared without my prior consent
I consent to photos and videos of my child being shared for education and training purposes including in presentations used for wider professional and practitioner training
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