Consent for Physiotherapy
Patients Name:
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First Name
Please include surname if it is different to your own as registered at the vets
Owners Name*:
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First Name
Last Name
Email
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example@example.com
Veterinary practice
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Address
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Street Address
Street Address Line 2
Parish
Post code
Any medication given (prescription or non prescription)
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Do you have any disabilities that you would like to make us aware of so we can make the consultation better for you too?*
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Check the boxes to agree to the following GDPR questions:
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I am the owner of the above patient.
I understand it is my responsibility to settle all bills as they are due, following the therapy. Any other costs will be discussed before they are incurred.
Sarah Lewis Veterinary Physiotherapist cannot guarantee payments will be made by your insurance company as the policy is between you and the policy company.
I am happy for the use of my animals story and photo to be used in public media (no surnames will be used)
I am happy for Sarah Lewis Veterinary Physiotherapist to share my records with the other veterinary professionals involved directly with my animal. This includes paraprofessionals e.g. hydrotherapist
I am aware Sarah Lewis Veterinary Physiotherapist will hold my name, address, email and phone numbers. Please note the RCVS advise keeping records for 7 years minimum.
I understand Sarah Lewis Veterinary Physiotherapist will use email for any necessary correspondence with regard to their service to my animal and bill receipts.
I am happy for Sarah Lewis Veterinary Physiotherapist to contact me via email for occasional newsletters and service feedback.
I understand I can request to have my data removed at any time and Sarah Lewis Veterinary Physiotherapist has given contact details to do this.
I am aware that I am liable to pay for a full session (£55) for missing an appointment without contacting Sarah Lewis Veterinary Physiotherapist to cancel or rearrange.
Check the box to say you under stand that with physiotherapy, sometimes the ailment may seem to get worse before it gets better. This is rare but can be the body adjusting to the new regime:
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I understand this may occur.
What is your main goal for physiotherapy to achieve?
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How did you hear about Sarah Lewis Veterinary Physiotherapist?
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Signature
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Submit
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