Online Physiotherapy Consent Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

Town/City

Post Code

Email

example@example.com

Phone Number

Area CodePhone Number

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Area codePhone Number

The purpose of an exercise class/programme is to help you achieve health and wellbeing goals. The programme you have agreed to attend and participate in will be based upon your present activity/exercise level, as per tutor/physiotherapist assessment, and the goals that you wish to achieve.

All exercise and activities will be explained and demonstrated and I understand that I am free to ask questions about any of the activities/exercises.

Yes, I understand I can ask questions

It is recommended that all class attendees should have a full physiotherapy assessment prior to enrolling for any class to help identify which is most appropriate for my ability and to minimise risk. If I choose not to, I accept full responsibility for my safety during participation in the class

I have had a physiotherapy assessmentI would like to book a physiotherapy assessmentI do not wish to have a full assessment and accept full responsibility for my safety

Any exercise programme carries with it an element of risk. The sessions will be designed to minimise the risks whilst providing an effective exercise/activity intensity. Please inform the instructor if, for any reason (such as illness or injury which might be aggravated by exercise, or eating certain foods), you should not participate in an activity.

I understand that it is my responsibility to ensure my own safety. I take full responsibility for my own health and safety whilst participating in the on-line (virtual) exercise class/es.

Yes, I understand that my health and safety is my responsibility

If at any time, you feel undue pain or excessive discomfort, stop the activity and inform the instructor of your symptoms. You are free to withdraw from any activity at any time you wish.

I agree to take part in the programme described to me by the instructor. The nature, purpose, risks and benefits have been explained to me and I understand what is required of me and that I may withdraw at any time.

Yes, I understand

Please type your Full Name*

We accept this as your signature