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REGISTRATION AND CONSENT FORM



Please take a few moments to fill in some details.


Please note that treatment consent and GDPR consent are essential requirements
for us to be able to provide our services. If you do not tick these fields and
sign we will not be able to treat you.


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Forename:

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Surname:

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Address:

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Postcode:

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Date of Birth:

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Select a Date



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Gender:

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FemaleMaleNot SpecifiedOther





Preferred Contact number:
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How did you hear about us? :
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Click here to select




COVID 19 Risk Consent (Required for face-to-face consultations)


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Please click here to read our Explanation of Physiotherapy Services during the
Coronavirus Crisis

Show when Covid terms has ["Please click here to read our Explanation of
Physiotherapy Services during the Coronavirus Crisis"]


Please ask your physiotherapist before signing this form if you have any
questions about this information.


Your declaration and signature:


I confirm I have read and understood the content of this consent form, including
that there is a risk of coronavirus infection in attending a face to face
consultation;
I confirm that I am willing to accept that risk and any consequences thereof;
I agree to undertake hands-on treatment despite this risk.
I confirm that I give consent to the above until I expressly revoke this
consent.
I have had the opportunity to ask all the questions I wish to, and all of my
questions have been answered to my satisfaction.


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SIGNATURE:

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Sign here



Are you a Chaperone?
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Yes
No



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Treatment Consent (Required)


I consent to the assessment and performance of therapy adjustments and other
procedures, including various modes of physical therapy and those listed as
having an increased risk of adverse effects. I understand that the results of
any treatment are not guaranteed.
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Please click here to read full details of our Treatment Consent policy

Show when Treat consent is ["Please click here to read full details of our
Treatment Consent policy"]


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I hereby consent to the assessment and subsequent treatment being administered
by Sano Physiotherapy clinicians (this consent is valid for 12 months from the
date of signature). (Required before we are able to continue with treatment).



GDPR Consent (Required)


Pursuant to the provisions of current data protection law I hereby confirm I
have read and understand the content of this consent form. Please tick the box
to show you agree to this data that is collected being held and used for your
treatment or ongoing treatment and billing by Sano Physiotherapy. (Required
before we are able to continue with treatment).
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Please click here to here to read our full GDPR Consent policy

Show when GDPR Terms has ["Please click here to here to read our full GDPR
Consent policy"]


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I agree to this data that is collected being held and used for my treatment or
ongoing treatment and billing by Sano Physiotherapy.



Communcations Consent (Required)


Sano Physiotherapy may use automated or manual methods for contacting you during
your ongoing treatment for appointments, appointment reminders / changes and
treatment plans which are all ongoing and treatment related. During your
treatment period you will be contacted one or all of the following: telephone,
email and/or SMS. Please tick the box if you agree. (Required before we are able
to continue with treatment).


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I agree Sano Physiotherapy can contact me by either of these methods for
Appointments, Appointment reminders or changes, Treatment plans or any other
treatment related issue during my ongoing treatment period with Sano
Physiotherapy.



Surveys


As part of Sano Physiotherapy continuing improvements, developments and
monitoring, we would like to send you a survey link to be completed by
yourselves at the end of your treatment. The completion of the short survey is
optional, and the link will be sent to you by Email or SMS. Please tick the box
if you agree.


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I agree to Sano Physiotherapy contacting me by either of these methods to be
sent the survey link after my treatment.



Marketing


From time to time, Sano Physiotherapy can provide new treatments and offers. We
would like to send you information about our own products and services by email
and SMS.


If you agree to being contacted in this way, please select yes in the relevant
boxes


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Email

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SMS





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SIGNATURE:

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