CHAPERONE: With prior notice, we can provide a chaperone, or you can have a family member or friend accompany you during your treatment. Please make your preference known to a receptionist or your practitioner in advance of your appointment
I confirm that the information given on this form is the best of my knowledge true and correct and if any of the details changes I will immediately inform a representative of the Company.
I consent to divulge information regarding my condition; this includes permission and consent for the examination, and any treatment that may follow.I have read the terms and conditions set out above and agree to abide by them.
I confirm that I give consent for an assessment and any appropriate treatment (including, but not limited to, acupuncture and manipulation). I understand that I can withdraw from the treatment at any time, and will ask the practitioner, if I have an questions or concerns related to my treatment.
In consideration for the consultation and treatment received I accept full financial liability for all the services performed and items supplied, regardless if I have Health Insurance. I understand and agree to the payment criteria as detailed overleaf and that the Company will exercise their statutory right to claim interest (at 8% over the Bank of England base rate) and compensation for debt recovery costs.
CANCELLATION OF APPOINTMENTS a cancellation fee for the full treatment will be charged if you fail to give 24 hours notice that you will not be attending an appointment.
PAYMENT for treatment is due at the end of each session. Payment can be made by credit card, debit card or BACS transfer.
PRIVATE HEALTH INSURANCE We can submit your invoices directly to your insurer for settlement if the following information is provided prior to your first treatment. If this information is not available you will be required to pay for your treatment at the end of each session until such a time it is made available. We will make very effort to ensure that your account is processed by your insurer however; it is the responsibility of the patient to ensure that their claim meets all the necessary criteria set down in their policy document. We respectfully remind patients that if your insurance company does not settle your full claim promptly or there is a shortfall then the liability falls to the patient to settle the account directly when requested to do. Failure to do so may involve us reluctantly instructing a debt collection agency.
DATA PROTECTION Information acquired about individual patients will become part of the data held on a computerised data base by the company in accordance with the Data Protection Act 1998
On occasion, Premier Therapies Ltd may wish to contact you with the opportunity to attend educational talks, relating to your condition and / or general health. Please initial below to confirm that you consent.