Home / Patients / Consent Form

Consent Form

Please read and complete this form before your first session. Fill it in on screen and print, or print it blank and sign it at reception.

Tip: choose “Save as PDF” in the print dialog to keep a copy.

U & I Medics®

RC 9900777

+234 707 422 0209

info@uandimedics.com

2nd Floor, 6 Matthew Adamu Str, Mabushi, Abuja

Physiotherapy Treatment Consent Form

To be completed by the patient, or by a parent or guardian for patients under 18.

Patient no. (office use)

1Patient details

Full nameDate of birthSexPhone numberEmailHome addressOccupationHMO & membership no. (if any)

2Next of kin / emergency contact

Full nameRelationshipPhone number

3Referral & reason for visit

Referred by (doctor / hospital / self)Date of referralMain complaint / diagnosisCurrent medication

5About your treatment

Your physiotherapist will first assess you and then agree a treatment plan with you. Depending on your condition, treatment may include:

Exercise therapy and gait training
Manual therapy and massage
Electrotherapy and shortwave therapy
Spinal traction
Sling suspension therapy
Heat and cold therapy

Possible risks. Most people have no problems. Some may have temporary soreness, stiffness, tiredness, light-headedness or skin redness after treatment, which usually settles within 24–48 hours. Serious complications are rare. Tell your physiotherapist straight away if anything feels wrong during or after a session.

Benefits. Treatment aims to reduce pain, improve movement, strength and function, and support your recovery. Results vary from person to person and cannot be guaranteed.

6Declarations

The information I have given about my health is complete and correct to the best of my knowledge. I will tell my physiotherapist about any changes.My physiotherapist has explained my assessment findings, the proposed treatment, its expected benefits, possible risks and the alternatives, and I have had the chance to ask questions.I understand that treatment may involve physical contact and that I may be asked to remove some clothing to expose the area being treated. I may ask for a chaperone at any time.I understand that I can refuse or stop any part of my treatment at any time without it affecting my future care.I consent to my records being kept securely in U & I Medics' electronic medical record and shared with my referring doctor or HMO where needed for my care, in line with the Nigeria Data Protection Act 2023.

Clinical photos / videos

For my clinical records only, to track progress.

I agree I do not agree

Telemedicine

Consultations by phone or video call, where suitable.

I agree I do not agree

I have read and understood this form, and I consent to physiotherapy assessment and treatment at U & I Medics.

7Signatures

Patient name

Signature

Date

Parent or guardian (if the patient is under 18)

NameRelationship

Signature

Date

Physiotherapist (office use)

Name

Signature

Date

Consent Form

Physiotherapy Treatment Consent Form

1Patient details

2Next of kin / emergency contact

3Referral & reason for visit

4Health screening

5About your treatment

6Declarations

7Signatures