New Patient Registration

London City Physiotherapy

 

Registration, Declaration of Consent and Terms of Service

 

 

Please note, fields denoted with an asterix ("*") require completion.


GoogleLondon City PilatesInsurance CompanyWord of MouthPavement signConsultant/GPMy employer

Consultant/GP details

If you were referred to us by a consultant or GP, please provide their details:

Insurance details

Do you have a policy excess?

YesNo

Self-pay (Physiotherapy fees)

Initial assessment: 1 hour £102, 45 mins £78
Follow-up: 30 mins £65

All fees must be settled on the day of assessment/treatment. Block payments can be made in anticipation of a course of treatment. Receipts are available upon request.

If you are claiming back any fees, we suggest you contact your insurance company for any details which may be required in advance.

Declaration of Consent and Acceptance of Terms

I consent to treatment with London City Physiotherapy (“LCP”), which may include manual therapy, physical manipulation and physical contact. I understand I may need to be referred to a specialist practitioner to facilitate my treatment, which may involve sharing personal information with a third-party clinician. I understand that this consent may be retracted at any time and that any records relating to my treatment, or copies of my personal information, other than those which must be retained by law, can be provided upon request. I also understand that I can request that any personal details are deleted at any time.

I understand and accept that I am responsible for payment for each appointment, including those that my insurer doesn’t cover in full. I understand that a cancellation policy applies to all appointments and that I will be charged the full consultation fee should I fail to provide at least 24 hours’ notice to cancel, amend or re-schedule an appointment. I understand that it is my responsibility to arrive on time for any scheduled appointment and that I may still be charged the consultation fee if I fail to arrive at the confirmed appointment time.