Registered Osteopaths Health Focus

Registered Osteopaths Health Focus

Marion Jones BSc (Hons) Ost. Canal Yard

Claire Arnold BSc (Hons) Ost DPO Welshpool

Mark Chadwick BSc (Hons) Ost.

Patient Information Form

Please take as much time as you need to fully read the following information and if necessary ask questions of the Osteopath. When satisfied and after discussion with the Osteopath, please sign the attached consent form. You are entitled to withhold or withdraw your consent to an examination or treatment at any time, even after signing the form.

·  The Osteopath will ask you detailed questions about your complaint, past medical history, general health and any medications or supplements you may be taking.

·  In order to examine you, it is normal to ask you to undress down to your underwear. You will never be asked to remove your underwear.

·  The Osteopath will need to see and touch the area that is causing pain and often, other areas of your body which may be related to your condition. The purpose of this will be explained during the examination. If you would be more comfortable we advise patients to bring a pair of shorts with them or we can provide them.

·  You are welcome to bring a chaperone to attend any examination, procedure or treatment performed by the Osteopath. Under 16’s or adults who are unable to make their own decisions must be accompanied by a parent or guardian. Should you wish to have a chaperone today and have come alone this may be possible to arrange, alternatively your appointment will be moved to a more convenient time for both parties.

·  During the examination you will be asked to perform simple movements both standing and when on the treatment table. Joint mobility, muscle tone and posture may be examined along with other tests such as blood pressure and reflexes. At no time should this be too painful, if it is please tell the osteopath.

·  There are a number of techniques an Osteopath may use including massage, articulation, mobilisation, thrust techniques and cranial. If any of the techniques have a risk it will be explained to you but please do ask if you have any concerns.

·  Certain procedures that form part of the practise of osteopathy may be invasive in nature or involve intimate areas of the body. Before undertaking such procedures, your Osteopath must obtain your written consent. Should the occasion arise the procedure will be fully explained and you will be asked to sign a separate consent form. You may defer or refuse treatment should you feel uncomfortable at any time.

·  If your Osteopath feels that treatment would be inappropriate for your condition they will explain why this is and may refer you to your GP or another therapist if necessary.

·  The diagnosis and treatment plan will be discussed with you. Please do not hesitate to ask the Osteopath to stop the treatment and explain anything she says or does during your appointment. You will also be given advice to support your treatment.

·  For the first 24 hours or so after your treatment you may feel uncomfortable. Please feel free to ring the clinic and ask to talk to the Osteopath if you need to. They can be contacted, on your behalf, by reception in an emergency.

·  It may take several sessions before your condition is relieved, however, every case is individual so your Osteopath may be unable to say at the first appointment how many sessions you will need.

Confidentiality

·  All the information you provide us is treated with strictest confidentiality, is protected by the Data Protections Act 1998 and will not be passed onto third parties.

·  However, we are legally required to disclose information relating to criminal activity and we may break confidentiality in light of evidence relating to ongoing child abuse, the risk of serious harm to another person, if we have serious concerns for your safety or if you are actively suicidal.

·  If concerned about your safety the Osteopath will contact your GP, or another professional, hopefully with your consent.

Payment & Fees

·  Payment is required after every treatment. Insurance claims must be made retrospectively of treatment.

·  We require 24hrs notice of cancellation of an appointment otherwise you will incur a missed appointment fee.

Complaints

·  If you have a complaint or concern about the level of care you have received from an osteopath or any other member of staff, please let us know as soon as possible. We hope that most problems can be sorted out quickly and easily with the person concerned, however, if your problem cannot be resolved in this way and you wish to make a complaint, we will provide you with a copy of the clinic complaints policy which will explain how to proceed.

Your contact details

This form asks for your contact details purely for our records and to be able to contact you in an emergency.

Please complete the following. In case of a child please give their details and sign on their behalf.

Title……..Name…………………………………………......

(Please include any middle names)

Address…………………………………………………………………………………………

………………………………………………………………… Postcode…………………….

Telephone: Please give as many numbers as possible.

Home…………………………………. Work…………………………………………………

Mobile………………………………….

Email………………………………………………...

How did you hear about the practice? (Please circle)

Word of mouth Yellow Pages Yell.com

GP Health Visitor Midwife

Internet site (please name)……………..

Other…………………………..

Consent for examination and/or treatment

I can confirm that I have read and understood the above information sheet and that

My Osteopath : MARION JONES / CLAIRE ARNOLD / MARK CHADWICK

Has explained to me…………………………………………………………… (Your name)

That the Osteopath will carry out the following procedures and the reasons for using such procedures………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

(Osteopath to describe the procedures to be employed and the reasons for using such procedures)

Signed……………………………………………………….. Date……………………….

I confirm that I have been offered the service of a chaperone for the examination and/or treatment (indicate a, b or c)

a. Suitable person from my Osteopath’s practice (cannot be your Osteopath’s spouse)

………………………………………………………………………………………………….

b. Relative or friend (of patient)

…………………………………………………………………………………………………..

c. I DO NOT require a chaperone to be present during the treatment described above)

Signed……………………………………………………………….. Date………………

I can confirm that I am responsible for the payment of fees (including fees incurred due to missed appointments or late cancellations.)

Signed……………………………………………………….. Date……………………….