Adult Registration and Consent Form

Below is the wording of the registration and consent form that you (or a person with legal responsibility for you) will be required to complete before your first meeting with your practitioner. Please arrive a few minutes before your scheduled appointment time so that our receptionist can guide you through the process.

This is presented purely for your information – please do not try to print and complete the form yourself.


REGISTRATION AND CONSENT FORM

Thank you for booking an appointment with our practice. Before you can be seen, we must ask you to read and sign the following consent form, to provide your contact details and to read and sign the data consent form overleaf.

Consenting to Consultation – for all Therapies

I confirm that I have viewed the Practice website, read the Practice leaflet or am an existing patient / client.

I understand that my practitioner will ask detailed questions about my background, medical history and lifestyle, as well as any symptoms I may be experiencing. I recognise that giving accurate answers to these questions is very important, as it will help them to reach a better understanding of my situation.

I understand that they will keep a written record of what we discuss, that this will be treated as confidential and processed only in accordance with General Data Protection Regulations and that I will have to consent to this.

I understand that my practitioner will draw conclusions from what I tell them and use these conclusions to develop a therapeutic plan with me. I recognise that fulfilling this plan may involve several visits.

Consenting to Examination and Treatment – for Manual Therapies only

I understand that my practitioner is likely to need to examine the area(s) of my body where I am feeling discomfort, but also that they may need to examine other areas which might be contributing to my symptoms.

To enable this, I understand that I may be asked to remove some layers of clothing down to, but not including, my underwear, but only if I am comfortable to do so. Alternatively, I understand that I am entitled to wear shorts and a t-shirt or close-fitting garments if I prefer.

I understand that my practitioner may need to touch appropriate areas of my body, to feel for any tightness or tenderness in the tissues and stiffness in the joints. I understand that they will explain what they are doing both in advance and as they go along and that, if I am uncomfortable with any part of this, I have the right to ask them to stop at any stage, without prejudicing any future treatment.

I understand that I am welcome to invite a friend or relative to accompany me throughout my appointment.

I recognise that treatment itself might involve a range of hands-on techniques focused on releasing tension, stretching muscles and mobilising joints, or other techniques. I understand that acupuncture or dry needling will involve the insertion of acupuncture needles into my skin. I understand that exercises or other lifestyle advice might be offered.

I understand that sometimes further tests, such as blood tests or scans, may be required before treatment can begin, and that, rarely, the practitioner might diagnose or have concerns about a condition that they are unable to treat and may refer me to my GP or another appropriate health professional.

I accept that, although treatment is usually a very gentle process, I may experience some discomfort during treatment. I understand that my practitioner will warn me if they think that a technique is likely to be uncomfortable and that they will stop if I tell them that I am feeling too much discomfort. I also understand that my practitioner will explain any specific or exceptional risks associated with any particular techniques and that I have the right to decline any such techniques, should I so choose.

I accept that, following treatment, I may experience some mild soreness in the area of the body that was treated but recognise that this will normally resolve within 48 hours. I understand that, in very rare circumstances, I might experience serious or unusual symptoms after treatment and that I can contact my practitioner for advice.

Subject to the above conditions and subject to ongoing discussion and continued and specific agreement, I hereby consent to appropriate consultation, examination and treatment, as described above.

Print name *: ………………………………..        Signed: ………………………….        Date: ………………

(* If acting as a legal guardian / responsible person, please state your role / authority:…………………………………….)


Registration Details (Please print clearly.)

Full Name:                                                                DoB:                                Occupation:

Address:

Hobbies / activities / exercise

 Telephone (home, work, mobile):


GDPR – DATA PROTECTION AGREEMENT  

I explicitly consent to you creating and storing medical records concerning my treatment, which may include details concerning my medication, treatment and other issues affecting my health conditions, in accordance with the General Data Protection Regulation (GDPR). I understand that these records will be retained for eight years after treatment is ceased (or, if I am currently aged 16 – 18, until I reach the age of 25, whichever comes later) in order to comply with the Institute of Osteopathy legal guidelines. I understand that these records will be processed in accordance with the Practice’s 2018 Privacy Notice, a copy of which I have seen or been given access to.

I have read and understood the above information and give my explicit consent:

Signed *……………………………………………..                     Date:   ………………………………

Patient / client full name ……………………………………………………………………………………………

 

*  If acting in the capacity of a legal guardian / responsible person for a patient / client who is unable to give consent, please state your name and role / authority here:                   …………………………………………………………………………………………………


For appointments and administrative purposes, I understand and agree that the Practice will need to contact me by telephone [   ]. (Please tick to confirm your consent. This one is essential for us to manage your appointments; all other selections are optional.)

If necessary, for the same administrative reasons, I agree that the Practice might also contact me by:

[   ] Email (see address below)                                                [   ] Text

[   ] Post

Other Information

For the purposes of promoting my healthcare, including information about lifestyle and / or exercise advice, I understand that my therapist or the Practice might wish to contact me with information that may be of interest to me and that this would typically be done by email.

For providing such other information, I agree that my therapist and / or the Practice can stay in touch with me using email [   ].

My email address is:

If necessary, for the same purpose of providing such other information, I agree that the Practice might also contact me by:

[   ] Telephone                                                             [   ] Text

[   ] Post

Signed: ……………………………………………..                       Date: ………………………………

Osteopathy, cranial osteopathy, massage, acupuncture, counselling, craniosacral therapy, reflexology and reiki