The Arm Clinic
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Consultation Registration Form

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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(Required)
DD slash MM slash YYYY

Your Details

Payment details

Are you funding this treatment yourself (Self Pay) or do you have private medial insurance cover (insured).

Finance(Required)

GP / Physiotherapist Details

Additional Information

Affected arm
Affected Knee
Previous Investigations and Treatments for this problem(Required)
If you have had previous scans or x-rays for this problem:
DD slash MM slash YYYY
Seen a previous Limb Surgeon about this problem

Any other medical conditions

COVID

Have you or someone in your household got any of the below symptoms:
Have you or someone in your household been told you have confirmed COVID-19 in the last 14 days?(Required)
Have you been told you have been in contact with someone who has confirmed COVID19 in the last 14 days?(Required)
Have you travelled outside the UK in the last 14 days?(Required)
*not including countries specified by the government as exempt from isolation requirements

Signature and authorisation

Person Authoristion

I give permission for the following persons to arrange appointments and make payments and act on my behalf for administration:

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(Required)
Terms and Conditions(Required)

The Wilmslow Hospital,
52 Alderley Rd,
Wilmslow,
Cheshire,
SK9 1NY

Phone: 01625 545071/2/3

Important Links

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More Links

  • Privacy Notice
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  • Surgical Consent Form

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