Client pre-assessment & consent form

Please complete this form with client details so that we have everything we need prior to your visit.

Please complete this form with client details so that we have all the information we need prior to your visit. If you cannot complete the form yourself please ensure your power of attorney for medical issues reads and signs it on your behalf.

We would like to advise you that, due to the nature of the assessment and treatment we offer, we are happy for you to be accompanied by a chaperone if this would make you feel more comfortable.

Severn Physiotherapy LLP collects your data for clinical purposes only. The data is stored along with your medical records with our GDPR compliant software for 10 years then deleted. Please see our website for our policy on data protection and privacy.

1. Full name of patient/client

2. Full name of person completing form (if not the patient/client)

3. Best way to contact patient/client (or person completing the form) Email or phone. By completing this you give permission for us to leave voicemails and emails which may sometimes include clinical information.

4. Address Address of patient/client — this can be own home, care home, temporary residence

5. Date of birth Date of birth of patient/client

6. Medical Professionals GP name and practice, consultant name and hospital

7. Emergency contact / Next of kin Name, contact number and relation to patient/client

8. Respect Form As we work with people who are sometimes very unwell, we need to be aware if you have made decisions about how you would like to be treated during an emergency. Please see www.respectprocess.org.uk for more information and talk to your GP.
Does the person currently have a DNACPR in place?

yesno

9. What would you like us to help you with? Please give as much information as you can

10. Relevant medical history, operations etc Please include any relevant scans/XRAY results etc. This can be obtained directly from your GP by asking for a GP summary, or emailed to us at hello@severnphysiotherapy.co.uk

11. Medications — please give as much information as you can This can be obtained directly from your GP by asking for a GP summary, or emailed to us at hello@severnphysiotherapy.co.uk

12. Are there any known risks such as pets in the home? Although we love animals, please keep any pets under control during visits.

Informed consent and sharing of your information

In order for us to assess and treat you effectively we are required to liaise with your GP and any other appropriate health and/or social care professionals with relevant information sharing only.

In addition we are required to report any safeguarding issues to local authorities. We will discuss this with you first.

In the case of a legal dispute, we will share the details of your case in accordance with the law.

You may request any data which we hold for you at any point and we will send it to you either electronically or in paper format to your provided address within 28 days. You can:

Request a copy of the information we hold about you.
Request a correction to the information we hold about you.
Withdraw your consent for your non-clinical information to be stored.
Request your non-clinical information to be deleted from our system.

For more detail please see our Data Protection and Privacy Policy.

Management may contact you as an opportunity to feedback about your therapy. This will be done by phone call if appropriate and your clinical notes will not be shared.

Photographs and videos

We find that videoing your movements and exercises can be a really helpful way to track your progress and to record how to do your exercises with the therapist's prompts. If you have your own smartphone we can use this and we will not store this ourselves. However the therapist may ask if you are happy to use their device and then they can store to your notes and show you your progress. In this case the therapist is obliged to upload the images/videos to your clinical notes and then delete the data from their device within 24 hours.

If we would like to use your photos or videos for marketing (online or print) we will discuss with you and ask for you to confirm before doing so. We will never share any photographs or videos for marketing purposes without your prior consent.

Infection Control and Risks

When a clinician visits you at home there is a risk of spread of infection. We maintain high standards of hygiene using hand washing, equipment cleansing and wear PPE as required. We follow local up to date Covid guidelines. We will always phone you if your clinician feels unwell before your visit and you always have the choice to postpone for no fee.

Cancellation Policy

Please note that we operate a Cancellations Policy.

If you need to cancel with more than 48 hours' notice of your appointment there will be no charge.
If you cancel with 48–24 hours' notice you will be charged 50% of the appointment fee.
If you give less than 24 hours' notice of a cancellation you must pay the full fee.

We encourage you to phone 01275 400466 to cancel a visit with as much notice as possible.

Complaints Process

We strive to provide the best standard of care at all times. However, if you have concerns about your therapy session with one of our team, please refer to our complaints process and follow the guidance. We have a positive, open attitude to complaints and consider them learning opportunities.

13. Please state that you understand all of the above and agree Client to agree or the Medical Power of Attorney on behalf of the client

Yes — I have read and agree to all of the above.

14. Signature Type your full name to sign — Client or Medical Power of Attorney

15. Date