Child Registration and Consent Form

Below is the wording of the registration and consent form that you will be required to complete before your child’s 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 – CHILD

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

Consenting to Consultation – for all Therapies

I confirm that I have visited the Practice website, read the Practice leaflet or that my child is an existing patient / client.

I understand that the practitioner will ask detailed questions about my child’s background, medical history and lifestyle, as well as any symptoms he/she may be experiencing. I recognise that giving accurate answers to these questions is very important, as it will help the practitioner to reach a better understanding of my child’s 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 the practitioner will draw conclusions from what we tell them and use these conclusions to develop a therapeutic plan with us. I recognise that fulfilling this plan may involve several visits.

Consenting to Examination and Treatment – for Manual Therapies only

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

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

I understand that the practitioner may need to touch appropriate areas of my child’s 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 either of us is uncomfortable with any part of this, we have the right to ask the practitioner to stop at any stage, without prejudicing any future treatment.

I understand that my child must always be accompanied by me or another responsible adult during any visit here.

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 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 my child to his/her GP or another appropriate health professional.

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

I accept that, following treatment, my child 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, my child might experience serious or unusual symptoms after treatment and that I can contact the practitioner for advice.

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

Print name: …………………………………         Signed: ……………………………        Date: ……………

I confirm that I am acting in the capacity of parent / legal guardian (please circle) for the child named below .


Registration Details (Please print clearly.)

Full Name:                                                                    DoB:                            Occupation:

Address:

Hobbies / activities / exercise

 Telephone (home, work, mobile):

GDPR – CHILD DATA PROTECTION AGREEMENT 

I explicitly consent to you creating and storing medical records concerning the treatment of the following child, for whom I have parental / legal responsibility:

……..………………………………………………………………………… .

I understand that this may include details concerning medication, treatment and other issues affecting health conditions, in accordance with the General Data Protection Regulation (GDPR).

I understand that these records will be retained until the child reaches 25, or for eight years after treatment as an adult is ceased, whichever is the later, in order to comply with the Institute of Osteopathy legal guidelines. I understand that these records will be processed in accordance with your 2018 Privacy Notice, a copy of which I have seen or been given access to.

I have read and understood the above information and I confirm that I have the authority to give explicit consent on behalf of the child named above:

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

Print full name: ………………………………………………………………………………………………

I am acting in the capacity of parent / legal guardian (please state which) …………………………………………….. .


For appointments and administration purposes, I understand and agree that the Practice will need to contact us 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 us by:

[   ] Email                                                         [   ] Text

[   ] Post

Other Information

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

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

My email address is:

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

[   ] Telephone                                                 [   ] Text

[   ] Post

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

Advertisements

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