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?

YesNo

Have you ever experienced chest pain whilst exercising?

YesNo

Do you suffer from epilepsy?

YesNo

Do you suffer from vertigo or loss of balance?

YesNo

Do you suffer from anxiety or drop attacks?

YesNo

Do you have a pacemaker, heart condition or blood pressure problems?

YesNo

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 ?

YesNo

In event that my insurer did not settled the account within 45 days of invoice, I agree to pay the full amount personally.

Missed appointments will be charged for unless 24-hour notice of cancellation is given.

I confirm that all information provided is correct and give consent to Physiotherapy Treatment that may involve telehealth management, physical contact and modalities for instance electrotherapy and dry needling that will be included in the treatment at Meyer & Associates Sports Physiotherapists.

New Patient Information

GDPR Consent

Hours & Info

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