Physical Therapy Registration Form

Please complete this form and then return the same via email. All details will be checked prior to acceptance and the information provided will be entered into our database for future correspondence and reference. Please complete all sections.

(Part 1)Information

Title:
Owner/Decision Maker Name:
Practice Manager Name:

Services:

Please tick as appropriate

Physiotherapy
Osteopathy
Chiropractic

(Part 2)Clinic Details

Name of Clinic:

Preferred Correspondence Address (Where all main communications will be sent)

Address:
Tel Number(s): / 1) / 2) / 3)
Fax:
EEmail:
Email:
Billing Email:

(Part 3) Main Treatment Address (Where patients will be examined/treated)

Address:
Tel Number(s): / 1) / 2)
Opening Hours

Additional Treatment Addresses

Opening Hours
Additional Address:
Tel Number(s): / 1) / 2)
Opening Hours
Additional Address:
Tel Number(s): / 1) / 2)

(Part 4) Agreed Terms

Cost of Initial Assessment
Cost per Treatment Session
DNA Charge (No 1st DNA Charge)
Agreed Payment Terms / 120 Days
Number of Treatment Addresses
(Part 5) Additional Information
Answering Machine Service
Residential/Commercial Building
Home Visit Radius (Miles)
Parking Available*
Disabled Facilities**
Practitioners – Male, Female or Both
CRB/ DBS checked Practitioners
Any additional Languages spoken by Treating Practitioners

Overland Health ensures that the claimants are examined by experts with experience in the relevant areas, please complete the following by ticking the appropriate boxes (any boxes that remain unchecked will be assumed you do not wish to receive cases within this area):

(Part 6) Facilities:
Hydro-Therapy
Gym Facilities
Neurological Facilities
Acupuncture
Heat Therapy
Ice Therapy
Electro Therapy
Laser Therapy
Ergonomic/Work Station Asses.
IFC
Mobilisation and Manipulation
Neuromuscular Electrical Stimulation
Pain Management
Taping
Trigger Point Dry Needling
Ultrasound Treatment
Shock-Wave Therapy

(Part 7) Confirmation

1)The information provided on this form is to the best of my knowledge true and correct.

2)I agree to submit photographs of key facilities and reception area/s along with the registration form via email to

3)I agree to offer my professional services in relation to working as an associate for expert treatments and provide compliant reports and treatment in line with the written instructions provided by you.

4)I agree to submit my signed contract within 7 working days and confirm that I will adhere the terms and conditions contained within the same.

Signature: / Date:

PLEASE KEEP SIGNATURE INSIDE THE BOX

Only hand written signatures are accepted

Overland Health is a trading name of Overland Health Ltd. | Registration No. C49864

Postal Address:4 The Courtyard, Calvin Street, Bolton. BL1 8PB
Email: |Tel:0344 241 3351 |Web: