Consultation Registration Form Step 1 of 7 14% Thank you for contacting us and arranging a consultation at The Arm Clinic. We hope that we can make the experience as stress free as possible. In order to try and help, in what can be a very stressful time, we will explain and offer you all of the alternatives and allow you to make the decisions regarding YOUR body and YOUR treatment.Name of consultant*Prof Len Funk (Shoulder)Mr Mike Walton (Shoulder)Prof Adam Watts (Elbow, Hand & Wrist)Mr David Murray (Hand, Wrist & Elbow)Mr Neil Jain (Shoulder & Knee)I can't remember my consultant's nameHow did you hear about us?*First Name*Last Name*Email Address* Date of Birth* Your DetailsPostcode*Address*Home Tel*Work TelMob Tel Payment detailsAre you funding this treatment yourself (Self Pay) or do you have private medial insurance cover (insured).Finance*InsuranceSelf PayingInsurance Company NamePolicy NumberAuthorisation Number GP / Physiotherapist DetailsGP Name*GP Address*Physiotherapist NamePhysiotherapist Address Additional InformationAffected armRightLeftBothAffected KneeRightLeftBothBrief History of the problem:Recommended/Referred From:Previous Investigations and Treatments for this problem*YesNoDetailsIf you have had previous scans or x-rays for this problem:YesNoWhere were they done (hospital or company name):Date Seen a previous Limb Surgeon about this problemYesNoNameDetailsAny other medical conditionsList of medicationsList of previous surgeries COVIDHave you or someone in your household got any of the below symptoms: a high temperature a new continuous cough a loss of, or change in, your normal sense of taste or smell Have you or someone in your household been told you have confirmed COVID-19 in the last 14 days?*YesNoHave you been told you have been in contact with someone who has confirmed COVID19 in the last 14 days?*YesNoHave you travelled outside the UK in the last 14 days?*YesNo*not including countries specified by the government as exempt from isolation requirementsAny other comments: Signature and authorisationPerson Authoristion I give permission for the following persons to arrange appointments and make payments and act on my behalf for administration:Authorised Person 1 NameAuthorised Person 1 RelationshipAuthorised Person 1 Phone NumberAuthorised Person 1 Email Authorised Person 2 NameAuthorised Person 2 RelationshipAuthorised Person 2 Phone NumberAuthorised Person 2 Email Authorised Person 3 NameAuthorised Person 3 RelationshipAuthorised Person 3 Phone NumberAuthorised Person 3 Email Please note that we cannot speak or correspond with anyone other than the patient (or registered guardian) without confirmed consent. This is in keeping with the Data Protection Act (2018), GMC regulations on patient confidentiality and HCA policies.Patient/Guardian Authoristion I guarantee payment for all services rendered within 28 days of being invoiced. The signature below confirms all the information provided herein is true and accurate. I understand that my email address may be used to send/request information or used for research purposes by or a member of the team but the addresses will NOT be passed onto any outside agency for any marketing purposes. By completing this form, professional athletes, are confirming that they are happy for the invoices regarding this and all future treatment(s) to be sent direct to their club or the club's agent as required but understand that payment of fees is ultimately their responsibility.Signatory for financial responsibility*I am the patientI am a guardian / act on behalf of the patientFirst Name (Guardian / representative)Last Name (Guardian / representative)Terms and Conditions* I have a read, understood and agree to the terms and conditions here. Signature*PhoneThis field is for validation purposes and should be left unchanged.
