Triage Form

Important Information For All New Patients

As a new patient please complete the Triage Form below.

Once the Consultants review your information our Practice Manager will contact you to discuss appointment availability.

Please do not hesitate to Contact Us if you need help filling out the form, or for more information.

Patient Details

Patient Name

Telephone

E-Mail Address

Address

Post Code

Date of Birth

Please Describe Your Problem

Pain

Numbness

Burning

Itching

Deformity

Poor Mobility

Walking Difficulties

Running Problems

Other Sports Related Injuries

Please give as much detail as possible regarding your problem

Patient Problem Details

Have you had any previous relevant medical treatment/investigations?

Do you suffer anxiety? (Yes/No)

Have you had any operations/long term illness/diseases?

What are your expectations for your appointment?

How did you hear about The Biomechanix Clinic?

Medical Details

GP Name

GP Address

GP Postcode

Medication List

Any Allergies

Private Health Insurance Details

If you have private health insurance and wish to use your policy to cover the cost of your treatment the clinic will need the following information please.

Do you have Private health insurance policy you wish to use for your appointment? (Yes/No)

Name of the Company you are insured with

Your Policy Number

The Authorisation Code for Treatment the Insurance Company have given you

Your Policy Excess Amount (This is the amount the Insurance Company will not pay toward your Treatment) This amount has to be paid to the Clinic at the time of your Appointment.

CONSULTATION APPOINTMENTS ARE NON-REFUNDABLE AND UNLESS CANCELLATIONS ARE MADE WITH A MINIMUM OF 24 HOURS NOTICE, UNLESS DUE TO EXCEPTIONAL CIRCUMSTANCES, THE CONSULTATION PAYMENT WILL BE CHARGED FOR IN FULL.

Accept Conditions