The Physiofy

Physiotherapy Treatment Consent Form

Please fill all required details before starting treatment.

Personal Information

Patient Full Name *

Age *

Gender *

Mobile Number *

Email Address *

Address *

Emergency Contact Name *

Emergency Contact Number *

Medical Information

Primary Health Condition *

Pain Area *

Existing Medical History *

Allergies *

Current Medications *

Previous Surgeries *

Doctor Reference (optional)

Treatment Consent

Consent Declaration

I hereby authorize The Physiofy and its healthcare professionals to provide physiotherapy assessment and treatment services. I understand the treatment procedures, benefits, possible risks, and agree to cooperate during the therapy process.

Terms & Conditions

I agree to physiotherapy treatment procedures. I understand results may vary from patient to patient. I understand that treatment may include manual therapy and exercise techniques. I agree to share correct medical information. I understand emergency medical care may be required in some situations. I agree to follow therapist instructions properly. I agree to payment and cancellation policies. My personal medical information will remain confidential.

I Agree to All Terms & Conditions

Digital Signature

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Patient Signature Name *

Date *

Therapist Name *