Consent Declaration
Staff at Ealing Physiotherapy Limited follow strict Infection control measures as set out by
the NHS England guidelines. I understand and acknowledge that there is a risk of becoming infected with COVID-19
by proceeding with clinical assessment & treatment, and I give my infomed consent to the staff at Ealing Physiotherapy
Limited to proceed with the same.
Following examination and assessment, a treatment plan will be explained to me. To benefit fully from the treatment,
continuity of the treatment plan is important. Therefore, I may be treated by another Chartered Physiotherapist during
holiday and sick cover.
3- I am responsible for payment for all treatment received. The fee for the initial consultation for physiotherapy is
payable even if the practitioner cannot help my condition. Fee structure: First consultation (45 Mins) - £ 80.00, Follow
up (30 mins) - £ 67.00, Sports Massage (30 mins) - £ 70.00. Home visits (60 mins)- £150.00.Additional charges may
apply for Shockwave Therapy, Ultrasound Scan /Guided injections and other treatments requiring longer durations.
Prices may vary. Please check with the treating clinician /reception for details.
I understand that I am responsible for the total cost of my physiotherapy and other related treatment if my
insurance claim is not honored. I will be liable for any amount unpaid. I agree to pay for any treatments that are
not covered under my policy within 7 days of receipt of Ealing Physiotherapy Limited’s invoice.
I agree to give a minimum of 24 hours’ notice for cancellations. This is inclusive of changing the day and time of my
appointment. The full fee is payable if notice is not received on time. If my slot is filled the fee will be waived. I
understand the clinic endeavors to send a text and / or email reminder, but it is not to be relied upon.
As part of the treatment, Manual Therapy, Electrotherapy, Acupuncture and Kinesio taping may be used in
combination or in isolation depending on clinical decision made by the treating clinician.If you have any allergic
reactions to any of the treatment modalities, please discuss this with the treating clinician prior to having the treatment.
The time spent on my treatment is entirely at the practitioner's discretion and is based on my specific condition. I may
find that the treatment is of longer or shorter duration than the times indicated above.Only one condition at a time can
be adequately dealt with. If time allows another condition may be dealt with, otherwise I may need to attend separately
for different problems.
I understand patients under 16 years of age will be accompanied by an adult (over 18) at all time.
I will endeavor to attend the clinic for my appointment on time. Half hour lists are kept and even 10 minutes delay
means that my valuable treatment time is being wasted. If I am late, I will be allocated only the time left of my
treatment. In the event that I am more than 20 minutes late, I cannot be seen, and this will be charged as a cancellation
with the full fee payable.
I understand that my GP will be informed of my progress unless I request otherwise
I understand that the clinic complies with GDPR (2018 to 2025) regulations, the full privacy policy is on our website or
available by request from reception.I do not wish to receive newsletters by Email.
