01206 912422 
info@jpphysiopilates.co.uk 
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Patient Registration 

PATIENT REGISTRATION FORM 

Please fill out the form below to register, and we will get back to you as soon as possible. 
Patient Details 
Emergency Contact 
News & Offers 
May I keep you up to date via email on any latest news & offers? 
Informing Your GP 
It is good practice to keep your GP informed of all aspects relating to your health. Please complete the following information if you are happy for me to contact your GP. 
Medical Conditions 
Do you have any medical conditions the clinician is required to know about such as: 
Diabetes, Epilepsy, Heart Conditions, High Blood Pressure, Allergies, Asthma, Cancer, Depression, Pace Maker, Metal Implant? 
Payment Details 
Please indicate how you’ll be paying your fees today: 
 
Medical Insurance or Third Party Payments 
If your treatment is covered by a Medical Insurer or Third Party, please fill in the required details below: 
Medical Insurance 
Third Party 
Cancellation Policy 
Please note that a discretional 100% cancellation charge will apply if you fail to give 24 hours’ notice of cancellation or if you fail to attend an appointment. This policy is deemed necessary to avoid denying appointments to patients who may be on the waiting list. 
Data Protection 
All information collected during your assessment and treatment at Jackie Parry Physiotherapy will remain strictly confidential under the terms of GDPR laws. I have read the Jackie Parry Privacy Policy and by signing below agree to the collection and use of information in accordance with this Policy. 
Chaperone Policy 
 
We do not offer a chaperone service; you are welcome to bring someone with you. 
Jackie Parry 
Chartered Physiotherapist Grad Dip Phys HCPC 
APPI Pilates Instructor 
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