Physiotherapy Referral Form

Physiotherapy Referral Form

Please complete all the fields below
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Your NHS number (if known)
Your GP*

First NameLast Name
GP Surgery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any medical conditions you have (if none please put N/A):*
Please list any medications that you are prescribed (if none please put N/A): *
Please explain in detail your reason for referral: *
How long have your symptoms been present? *
What are your expectations from your physiotherapy appointment?*
TelephoneEmail
I can confirm that the details provided are to the best of my knowledge true and accurate.
Signature*

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Sean Charman Physiotherapy Customer Privacy Notice

This privacy notice tells you what to expect us to do with your personal information.

·       Contact details

·       What information we collect, use, and why

·       Lawful bases and data protection rights

·       Where we get personal information from

·       How long we keep information

·       Who we share information with

·       How to complain

Contact details
Email

seancharman@hotmail.co.uk

What information we collect, use, and why
We collect or use the following information to provide patient care, services, pharmaceutical products and other goods:

·       Name, address and contact details

·       Gender

·       Date of birth

·       NHS/HSC/CHI number

·       Emergency contact details

·       Health information (including medical conditions, allergies, medical requirements and medical history)

·       Information about care needs (including disabilities, home conditions, medication and dietary requirements and general care provisions)

·       Test results (including psychological evaluations, scans, bloods, x-rays, tissue tests and genetic tests)

We also collect the following information to provide patient care, services, pharmaceutical products and other goods:

·       Health information

Lawful bases and data protection rights
Under UK data protection law, we must have a “lawful basis” for collecting and using your personal information. There is a list of possible lawful bases in the UK GDPR. You can find out more about lawful bases on the ICO’s website.

Which lawful basis we rely on may affect your data protection rights which are in brief set out below. You can find out more about your data protection rights and the exemptions which may apply on the ICO’s website:

·       Your right of access - You have the right to ask us for copies of your personal information. You can request other information such as details about where we get personal information from and who we share personal information with. There are some exemptions which means you may not receive all the information you ask for. You can read more about this right here.

·       Your right to rectification - You have the right to ask us to correct or delete personal information you think is inaccurate or incomplete. You can read more about this right here.

·       Your right to erasure - You have the right to ask us to delete your personal information. You can read more about this right here.

·       Your right to restriction of processing - You have the right to ask us to limit how we can use your personal information. You can read more about this right here.

·       Your right to object to processing - You have the right to object to the processing of your personal data. You can read more about this right here.

·       Your right to data portability - You have the right to ask that we transfer the personal information you gave us to another organisation, or to you. You can read more about this right here.

·       Your right to withdraw consent – When we use consent as our lawful basis you have the right to withdraw your consent at any time. You can read more about this right here.

If you make a request, we must respond to you without undue delay and in any event within one month.

To make a data protection rights request, please contact us using the contact details at the top of this privacy notice.

Our lawful bases for the collection and use of your data

Our lawful bases for collecting or using personal information to provide patient care, services, pharmaceutical products and other goods are:

·       Consent - we have permission from you after we gave you all the relevant information. All of your data protection rights may apply, except the right to object. To be clear, you do have the right to withdraw your consent at any time.

·       Legitimate interest:

·       To aid diagnosis and gain insight into possible contraindications to treatment and assessment.

Where we get personal information from
·       Directly from you

How long we keep information

We will not keep your personal data for any longer than is necessary considering the reason(s) for which it was first collected. Your personal data will therefore be kept for the following periods (or, where there is no fixed period, the following factors will be used to determine how long it is kept):

All data will be kept for a minimum of eight (8) years from when you no longer require our service or are discharged as client/patient from our care.
All data for children under the age of 18 years of age will be kept until they reach 25 years of age i.e. a minimum of seven (7) years.
This is line with regulatory arrangements for keeping medical and healthcare data in England and Wales.

Who we share information with
Others we share personal information with

·       Other health providers (eg GPs and consultants)

·       Organisations we need to share information with for safeguarding reasons

Duty of confidentiality
We are subject to a common law duty of confidentiality. However, there are circumstances where we will share relevant health and care information. These are where:

·       you’ve provided us with your consent (we have taken it as implied to provide you with care, or you have given it explicitly for other uses);

·       we have a legal requirement (including court orders) to collect, share or use the data;

·       on a case-by-case basis, the public interest to collect, share and use the data overrides the public interest served by protecting the duty of confidentiality (for example sharing information with the police to support the detection or prevention of serious crime);

·       If in England or Wales – the requirements of The Health Service (Control of Patient Information) Regulations 2002 are satisfied; or

·       If in Scotland – we have the authority to share provided by the Chief Medical Officer for Scotland, the Chief Executive of NHS Scotland, the Public Benefit and Privacy Panel for Health and Social Care or other similar governance and scrutiny process.

How to complain
If you have any concerns about our use of your personal data, you can make a complaint to us using the contact details at the top of this privacy notice.

If you remain unhappy with how we’ve used your data after raising a complaint with us, you can also complain to the ICO.

The ICO’s address:

Information Commissioner’s Office
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF

Helpline number: 0303 123 1113

Website: https://www.ico.org.uk/make-a-complaint

Last updated
29 August 2024
I confirm that I have read, understood and consent to the above privacy policy.

Informed Consent:

Physiotherapy is a healthcare service that is provided to manage a variety of conditions. The purpose of physiotherapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures such as mobilisation, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to reduce the length of recovery.

All procedures and treatments will be thoroughly explained to you before they are performed. Response to physiotherapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Sean Charman Physiotherapy does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physiotherapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns.

It is your right to ask your physiotherapist about the treatment they have planned based on your individual history, physiotherapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.

Consent

I consent to the assessment and treatment recommended and performed by Sean Charman Physiotherapy in accordance to the with the governing body’s professional guidelines. This may include mobilisations, manipulation, manual therapy techniques, soft tissue massage, or exercise therapy. I understand that before any treatment is carried out, a full explanation of the purpose and any risks of that treatment will be discussed, and that I should inform the clinician of my wishes at the time. By signing below I am in agreement with these conditions.

Chaperone

You are entitled a chaperone at your session. I understand that if I would like one I will inform Sean Charman Physiotherapy prior to my appointment.

Important Note

I understand and accept it is my responsibility to ensure prompt settlement of any fees. By signing below I am agreeing to these conditions.

Cancellation Policy

Please provide 24 hours advanced notice of your inability to attend your appointment, otherwise you will be charged in full for the appointment.

Data protection

All the information collected during the course of your assessment and treatment will remain strictly confidential under the terms of The Data Protection Act (2018).
I have read this consent form and understand the risks involved in physiotherapy and agree to fully cooperate, participate in all physiotherapy procedures, and comply with the established plan of care.
Signature

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