Diagnostic Ultrasound Informed Consent Form

Please complete our clinical information and injection consent form before any treatment takes place.

Name*

First

Last

Date of birth:*

Address: *

Street*

City/Town*

Postcode*

Phone *

Email *

Would you want us to email a copy of your clinic report to your Physiotherapist (or other health professional)?

Yes

Contact details:*

Physiotherapist*

GP*

Word of mouth*

Other*

Please describe your problem*

Diagnosis

Was there an injury?*

How long has this problem been present for?*

Have you had any investigations?*

What aggravates or eases your pain?*

Have you had any treatment?*

Please upload anything that might be helpful such as image reports as well as relevant reports from your doctor or specialist. Only one file can be attached per upload.

If you have files or images that could be helpful for us to better understand the problem that we are seeing you for then please upload them below.

10 files maximum per upload. Maximum total file size: 50MB · Allowed File Types: jpg,png,pdf,docx,doc,mp4,jpeg

Do you have any medical conditions?*

List of medications*

Declaration*

Please read the following COVID-19 specific declaration and confirm you have read and agree.

I currently do not have symptoms of COVID-19 and have not recently been in close contact with anyone who has COVID-19 symptoms.

Please make sure that all the required (*) fields have been completed otherwise the form will not submit !

If you have problems submitting the form then contact us on: 07999 923844

Diagnostic Ultrasound Informed Consent Form

Clinic contact