Physio Appointment Form

Your Name *

First Name Last Name

Your E-mail Address *

Contact Number *

Area Code Phone Number

Preferred Time

Day Month Year Hour Minutes AM/PM Option

Area of Injury / Treatment Required *

Services:

Member Consulation € 20.00 EUR

Academy Rate

Quantity

Non Member Consultation € 40.00 EUR

This rate is for non Academy members *Non-refundable*

Member Session € 45.00 EUR

Academy member rate

Quantity

Non Member Session € 55.00 EUR

Non Academy member rate

Quantity
Item subtotal: € 0.00 EUR

Pre Event Taping € 10.00 EUR

Total € 0.00 EUR

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please verify that you are human *

Please note due to COVID-19 :

All patients will be screened before entering the clinic. If a patient is experiencing any symptoms such as, but not limited to, fever, cough, loss of taste and smell, we ask to please avoid booking an in-clinic appointment. This is to ensure the safety of all patients and physio. We can also offer prebooked appointments via zoom call in the event a patient cannot attend the clinic. During a clinic visit, Patients and Physio will be required to wear a face mask throughout the session. Hands should be sanitised before and after the appointment.