BNV Application Form

Please complete as much information as possible to enable us to process your application as efficiently as possible. Some fields are mandatory and are marked with an *

  • Part One: About You

    Please select as appropriate
  • Please indicate your 3 priorities from the following list;
  • Who is your emergency contact?
  • Part Two: About your health

  • It is important that we understand all of your needs and any health risks from your participation. Please tick if you have any of the following medical problems. Having one of these conditions will not necessarily exclude you, but we do need to know about it. If you are unsure of your answers, please discuss participating in hydrotherapy with your GP.
  • Part Three: About Your Mobility

  • Part Four: Access and assistance

  • Part Five: About Your Water Confidence

  • If you require assistance whilst in the water from your own carer, please give your carer’s details below. Ensuring their safety is also important and we will contact them direct.
  • Part Six: Follow-up appointments

  • The Physiotherapist will review your application form and will be following up with a telephone call. These calls will take place on Weds 2nd February 2022 between 9.30am and 4.30pm
  • If you would like someone else to complete your telephone assessment, please indicate below:

Important note:
If you have completed the form successfully, once you click Submit, you will be redirected to a ‘thank you’ page. If you have missed out required information, this page will reload and you must scroll down and correct any omissions before submitting the form again. If you do not do this, all your information will be lost!