New Patient Information

Patient Information form to be filled out prior to your first appointment at Meyer & Associates.

Patient First and Last Name
Patient Email Address
Telephone Number
Date of Birth
Address Line 1
Address Line 2(Optional)
Town
Post Code
Referring Consultant(if there is one)
If you intend to claim from you Private Medical Insurance for your treatments, you should fill out this section.  If you will be settling the account personally, you can skip to the next section
Insurance Company
Policy Main Member
Policy Number
Authorisation Code
Number of sessions authorised
Are you pregnant?
Have you ever experienced chest pain whilst exercising?
Do you suffer from epilepsy?
Do you suffer from vertigo or loss of balance?
Do you suffer from anxiety or drop attacks?
Do you have a pacemaker, heart condition or blood pressure problems?

GDPR Consent

Meyer & Associates process personal data for the purpose of providing optimum healthcare, sending important updates to you, providing you with news about treatments, changes at the clinic and information about our services.
You can withdraw your consent at any time by email to enquiries@meyerphysio.com or by filling in this form.
Your personal information will never be passed to a third party unless we make a professional referral, contact your insurance or make an insurance claim. You will be notified and ask for consent before establishing contact with another professional or your insurance. For further details of how we process your personal information please see our Privacy Notice on www.meyerphysio.com/privacy-policy or request a hard copy on 0773 6731022.
We collect data for Physio First Quality Assured Practitioner (QAP) scheme and will be using anonymous information from your treatments.
Can the clinic contact you on: Email, text, telephone, post ?