Patient consent form

This form is designed to provide you, the patient, with comprehensive information regarding the physiotherapy services you may receive and to obtain your voluntary and informed consent to undergo physiotherapy assessment and treatment. Please read this document carefully and ask your physiotherapist any questions you may have before signing. 

Assessment Process

Your physiotherapist will begin with a thorough assessment, which may include:

• A detailed medical and health history interview
• A review of your current symptoms and concerns
• Physical examination of your posture, movement, strength, flexibility, balance, and other relevant functions.
• Discussion of findings and collaborative goal-setting

Therapy Duration and Prices

• Payment is made per session. The length of each individual session can vary as it will depend on your general ability and exercise tolerance. The session time will also include discussion, education and feedback where relevant.
• For initial (new patient) appointments the time is roughly 45 – 60mins. Priced at £50.
• For follow up (any appointment after the initial) the time is roughly 30-45mins. Priced at £35.
• Prices as of October 2025 and are subject to change.
• Travel Surcharge (over 5 miles from s40 3 Walton area): 45p per mile, will be agreed on individual basis prior to commencing treatment

Insurance

• For insurance claims you will be required to pay up front and claim reimbursement from your insurer. Please check with your insurer prior.

 Cancellation   

• If you need to cancel then 24 hours notice should be given where possible. If the session is cancelled within the 24 hours notice period then 50% of the session fee will be charged (at the therapist’s discretion).

Treatment Options

Based on your assessment, your physiotherapist may recommend one or more of the following interventions:

• Manual therapy (hands-on techniques)
• Exercise therapy or prescribed exercise programmes
• Thermal modalities (heat/cold packs)
• Education on posture, ergonomics, and self-management
• Assistive devices or mobility aids
• Braces/ splints
• Other evidence-based techniques as appropriate

The types of treatment recommended will depend on your diagnosis, your preferences, and the professional judgment of your physiotherapist. You may accept or refuse any proposed treatment and are encouraged to ask questions about any aspect of your care.

Potential Risks and Side Effects

Physiotherapy is generally a safe and effective intervention, but as with any medical treatment, there are potential risks, side effects, or discomforts. These may include:

• Temporary increase in pain, soreness, or fatigue
• Muscle or joint stiffness
• Bruising or minor injury from manual therapy or exercise
• Allergic reaction to materials (e.g., tapes, gels, lotions)
• Skin irritation from heat/cold packs

Your physiotherapist will take all necessary precautions to minimise these risks, and you should inform them immediately if you experience any side effects, discomfort, or worsening of your symptoms.

Confidentiality and Privacy

All personal and medical information collected during your assessment and treatment will be kept strictly confidential. Your records will be stored securely and only accessed by authorised personnel. No information will be shared with third parties without your explicit consent, unless required by law. Move Well Home Physiotherapy is registered with the ICO (information commissioner’s office) for data protection. 

Consent to Contact and Communication

By signing this form, you also consent to your physiotherapist or clinic contacting you regarding appointments, follow-ups, or relevant healthcare information, using your provided contact details. You may withdraw this consent, and your consent for physiotherapy services at any time.

Declaration of Consent

By signing below, you confirm that:

• You have read and understood the information provided above
• You have had the opportunity to ask questions regarding your assessment and treatment
• All your questions have been answered to your satisfaction
• You voluntarily agree to undergo physiotherapy assessment and treatment as recommended
• You understand that you can withdraw your consent at any time

Patient Details

Patient Signature

Physiotherapist agreement

I, Rachael Hall hereby agree to uphold these terms and conditions and to adhere to the aspects relating to my delivery of the service, HCPC registered (PH106783) and CSP (Chartered society of physiotherapy) registered.