The pdf document can be downloaded here: Osteopathic Consent to Treatment D Murgatroyd

PATIENT AND PARENT/GUARDIAN
CONSENT TO OSTEOPATHIC TREATMENT FORM

Consent to Osteopathic Treatment by Dr Damon Murgatroyd

**Note – both this AND the Data Protection Consent forms need completing

before you can be treated**

– I aim to provide safe and effective treatment for a wide range of conditions (osteopathic and musculoskeletal).

– To enable me to do so, you will be asked about both your current symptoms and your past medical history.

– You will be given a comprehensive medical examination.

– Your recommended treatment will be explained and discussed with you during/before treatment begins.

– Your examination and treatment may require the removal of some items of clothing. Tell me if this is a problem!

   Please wear suitable underwear or loose-fitting sports clothing. A screen for changing is available in the room.

– Towels, gowns and disposable shorts will be available if you require them.

– You are welcome to bring someone to attend your appointment with you.

– It is essential that you advise us if any of the information you have given here or overleaf changes at any time.

Terms of consultation:
– All fees are payable at the time of your consultation.
– Please note that you are responsible for all your treatment fees. You are advised to check the terms of any
insurance policy before you attend. (Please note that BUPA does not cover your treatment at Damon Murgatroyd Osteopathy.)
– Please give at least 24 hours notice if you need to cancel your appointment or a fee may be charged.
Consent:
I consent to osteopathic examination and treatment according to the above Terms of Consultation and the processing of sensitive data
under the General Data Protection Regulations 2018 (sign the separate form).
I confirm that all the information I have provided on this form is accurate and as complete as possible.
Please complete in BLOCK CAPITALS and provide as much information in each section as possible.

Your Full Name (Print name of patient): ……………………………………………………………………………………………….

Date of Birth: ………../……………/…………………………             Landline: ……………………………………………………….

Email: …………………………………………………………….              Mobile: …………………………………………………………

Address: …………………………………………………………………………………………………………………………………………..

…………………………………………………………………………..       Post Code: ……………………………

Signed: ……………………………………………………………….         Date: …………………………………..

Print Name of Parent/Guardian (If patient under 18 years of age): ………………………………………………………….

Parent/Guardian Signature:………………………………………………………………………………………….