Consent Form

The Ilkley Osteopathic Practice Ltd Consent Form

Patient Name: Mr/Mrs/Ms/Miss/Master/Dr ______________________________

Date of birth: _______/_______/_______

Occupation: _____________________________________

Address: ______________________________________________

____________________________________ Post Code: _____________________

Telephone Daytime: ___________________ Evening: _____________________

Mobile: ___________________________

Email address: _____________________________________________

Please tick to consent that you are happy to receive –
Appointment confirmations by email □
Appointment Reminders by text □

From time to time we will send you a practice newsletter by email. Please
tick if you do not wish to subscribe to this for the time being □

If the patient is aged 16 years or younger, please complete the following
as applicable:

Parents name: Mother____________________ Father__________________________

Guardian: __________________________________

Appointed carer: _________________________________

*Your personal details will not be disclosed to anyone outside the Ilkley osteopathic Practice without your permission.
I hereby consent to – The Ilkley Osteopathic Practice – to contact my general practitioner, either verbally or in writing, which may involve releasing details of medical information, notes held and/or treatment received at the practice.

GP Surgery ………………………………………………………………………………………

Patient or Parent/Guardian/Appointed Carer Signature……………………………….

Date……………………

Statement of Consent for adult patients
I confirm that I have read and understood the Practice Information Sheet V1.0 dated13Feb2014; I confirm that I will have an opportunity to discuss any concerns with the osteopath. I consent to receive osteopathic treatment on this occasion, but I understand that I can refuse treatment (or any part of treatment) now or in the future without jeopardising future treatment at this practice. I understand that it is important that I inform my osteopath of any concerns, reactions or discomfort associated with treatment. I understand that I can also request to see another practitioner at this practice.

Signature …………………………………………………………………

Print name in full……………………………. Date……………………

Statement of Consent for patients aged 16 years or younger
I confirm that I have read and understood the Practice Information Sheet V1.0 dated13Feb2014, and I consent, as parent, guardian or appointed carer to this patient receiving osteopathic treatment at this time. I understand that they can refuse treatment (or any part of treatment) at any time in the future without jeopardising future treatment at this practice.

Signature…………………………………………………………………………

Print name in full …………………………… Date …………………………

I.O.P._I.C.F._V2.0_07Feb2017