London City Physiotherapy

Registration, Declaration of Consent and Terms of Service
Your Details
How did you hear about us?

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Consultant/GP details

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

Insurance details

Policy details

Self-pay 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 politely 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.