Consultation Registration Form
Thank you for contacting us and arranging a consultation at The Arm Clinic. We hope that we can make the experience as stress free as possible. In order to try and help, in what can be a very stressful time, we will explain and offer you all of the alternatives and allow you to make the decisions regarding YOUR body and YOUR treatment.
Name of consultant
*
Prof Len Funk (Shoulder)
Mr Mike Walton (Shoulder)
Prof Adam Watts (Elbow, Hand & Wrist)
Mr David Murray (Hand, Wrist & Elbow)
Mr Neil Jain (Shoulder & Knee)
I can't remember my consultant's name
How did you hear about us?
*
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Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
Postcode
Email
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Format: 00000 000000.
Home Number
Please enter a valid phone number.
Format: 00000 000000.
Work Number
Please enter a valid phone number.
Format: 00000 000000.
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Payment details
Are you funding this treatment yourself (Self Pay) or do you have private medial insurance cover (insured).
*
Insurance
Self Paying
Insurance Company Name
*
Policy Number
*
Authorisation Number
*
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GP / Physiotherapist Details
GP Name
*
Address
*
Street Address
Street Address Line 2
City
Postcode
Physiotherapist Name
Physio Address
Street Address
Street Address Line 2
City
Postcode
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Additional Information
Affected arm
Left
Right
Both
Affected knee
Left
Right
Both
Brief History of the problem:
*
Recommended/Referred From:
*
Previous Investigations and Treatments for this problem
*
Yes
No
Details:
*
Have you had previous scans or xrays?
*
Yes
No
Name of hospital/company scans were performed at
*
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Any other medical conditions
List of medications
List of previous surgeries
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Person Authoristion
I give permission for the following persons to arrange appointments and make payments and act on my behalf for administration:
Authorised Person Name
First Name
Last Name
Authorised Person Relationship
Authorised Person Phone Number
Please enter a valid phone number.
Format: 00000 000000.
Authorised Person Email
example@example.com
Please note that we cannot speak or correspond with anyone other than the patient (or registered guardian) without confirmed consent. This is in keeping with the Data Protection Act (2018), GMC regulations on patient confidentiality and HCA policies.
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Patient/Guardian Authorisation
I guarantee payment for all services rendered within 28 days of being invoiced. The signature below confirms all the information provided herein is true and accurate. I understand that my email address may be used to send/request information or used for research purposes by or a member of the team but the addresses will NOT be passed onto any outside agency for any marketing purposes. By completing this form, professional athletes, are confirming that they are happy for the invoices regarding this and all future treatment(s) to be sent direct to their club or the club's agent as required but understand that payment of fees is ultimately their responsibility.
Signatory for financial responsibility
*
I am the patient
I am a guardian / act on behalf of the patient
Signature
Submit
Should be Empty: