Client Registration and Consent Form

Client Registration and Consent Form

Please complete the below form to register your horse for physiotherapy, we will contact you to make an appointment. Please note this form must be completed prior to commencement of treatment.
Owner details
Full Name*

First NameLast Name
Address*

House Name/Number

Address Line 2

CityCounty

Postcode
Is your animal kept at this address?*
Yard/keeper's address (where appointments will take place)*

House Name/Number

Address Line 2

CityCounty

Postcode
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Horse/Pony details
Name*
Age*
Breed*
Species

EquineCanineFelineOther
Sex
Sex*
Is your animal insured?*
Insurance company*
Veterinary Practice
Practice name*
Veterinary Surgeon*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Is your animal currently under veterinary care or investigation for any illness or injury?*
PLEASE NOTE: In the absence of a veterinary referral, physiotherapy may only be provided if your animal is fit and well, this is classed as maintenance care. If your animal is displaying signs of undiagnosed lameness or illness they will not be treated and will be referred back to your vets, you will be charged for the session in full.*

I agree
Additonal information (e.g. reason for requiring physiotherapy)
Please give details of current veterinary care/investigations*
PLEASE NOTE: a veterinary referral is required for all non-maintenance care, if there is no existing referral in place Sarah Read will contact your vets directly for a referral on receipt of this form.
Data Protection
Sarah Read (MVetPhys) holds information about you because you booked a veterinary physiotherapy session for your animal. The following personal data are stored;
- Name
- Address
- Phone number
- Email address
How I will use your data

All the above is stored electronically or hard copy and used to communicate with you by telephone and email. I will never contact you for marketing purposes. The legal basis for processing of your personal data, under the terms of the General Data Protection Regulation (GDPR), is that this processing is necessary for the purposes of the legitimate interests of Sarah Read as controller of the data collected. Your personal data will not be shared with a third party and will not be subject to any automated decision making or profiling.

Your rights
- Your data will be stored for the purposes described above for a maximum of 10 years
- You have the right to access the personal data I hold about you and to verify the lawfulness of its possessing
- You have the right to have any errors in the data I hold about you rectified
- Under certain circumstances you may have the right to have the data I hold about you erased or else place restrictions on how I process your data
- You have the right to object to how I am processing your data
- You have the right to complain to your Statutory Authority (the Information Commissioner’s Office in the UK) about my handling of your personal data
- Failure to provide me with the data requested may result in me being unable to provide you with the services offered
Contact me

If you have any questions or requests with regard to the personal data I hold about you, please contact me by sending an email to sarah@readvetphysio.co.uk

For more information about the General Data Protection Regulation and your rights, please visit the Information Commissioner’s Office at https://ico.org.uk
Please confirm:*

I agree
To comply with the Veterinary Act, the Animal Welfare Act and NAVP professional requirements:

I hereby give permission for Sarah Read (MVetPhys) to discuss treatment and share findings with my veterinary surgeon both verbally and in writing. I understand that Sarah Read (MVetPhys) may refer my animal back to the veterinary surgeon.

Insurance Companies

I understand that if my insurance company contacts Sarah Read (MVetPhys) for details of my animal’s case, Sarah Read (MVetPhys) is obliged to reply to them and allow them access to my records.
Please confirm:*

I agree
Signature*

Clear
Should be Empty:

Client Registration and Consent Form

Owner details

Horse/Pony details

Veterinary Practice

Data Protection