Thank You For Your Enquiry, Should You Wish To Proceed Please Confirm Consent Below

Self Referral Consent Form

Patient Details
Date:*
Date Format: DD slash MM slash YYYY
Patient's Name*
First Last
Patient's date of birth*
Date Format: DD slash MM slash YYYY
Please give email address of where we should send invoices
Consent
Consent to Data Storage
I agree
SP Therapy Services complies with General Data Protection Regulations 2018 (GDPR18). To effectively assess, treat and manage your problems it is necessary for us to collect and store your personal data. This may include assessment forms, treatment records and e mails containing information about your rehabilitation. The information may be digital, photographic or paper records. It may be shared with your Litigation team, other Professionals involved in your care such as your GP & Case Manager to assist in your rehabilitation planning and care. Your information is stored and disposed of securely in line with GDPR 18 and SP Therapy Services policies. Your information is never shared with third parties except as described above and will not be used for marketing purposes.
Terms and Conditions
I agree to the terms and conditions
I confirm I have received the terms and conditions via email and/or sourced them directly on the website.
Costs
I agree to the costs
I have received an email stating the costs of treatment and i am happy to proceed with assessment and ongoing treatment based on the costs provided.
I understand I can withdraw from treatment at any time without prejudice.
Yes
The charges for my treatment and the cancelation policy have been explained to me.
Yes
Consent to Assessment and Treatment
I agree to proceed with Assessment and Treatment
Any Additional Comments
Name
This field is for validation purposes and should be left unchanged.

Thank You For Your Enquiry, Should You Wish To Proceed Please Confirm Consent Below

Self Referral Consent Form

Patient Details

Consent