Patient Information

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

Title (Mr, Mrs, Miss, Dr, etc.)

Patient First and Last Name

Patient Email Address

Telephone Number

Date of Birth

Address Line 1

Address Line 2

(Optional)

Town

Post Code

GP Surgery

Please provide your GP Surgery name and their contact details if available

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. Please note that we no longer accept Bupa or AXA PPP.

Insurance Company

Policy Main Member

Policy Number

Authorisation Code

Number of sessions authorised

Price Listing 2023

1 Hour Physiotherapy appointment appointment : £95.00
Diagnostic Ultrasound scans: £170.00
Guided Steroid Injections (including medicine): £260.00 first body part.
£130.00 for second body part.
Private Medical Prescriptions £30.00 (MSK related).
Referral Letters & Reports: £35.00
Please advise when self payment is made, if an invoice is required.

Are you pregnant?

Yes No

Have you ever experienced chest pain whilst exercising?

Yes No

Do you suffer from epilepsy?

Yes No

Do you suffer from vertigo or loss of balance?

Yes No

Do you suffer from anxiety or have you ever been diagnosed with any mental health problems?

Yes No

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

Yes No

Do you have allergies? Please provide more information, if Yes.

No

Yes

Please list your medication & current dosages ?

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 ?

Yes No

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.

GDPR Consent

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