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Online Intake Form

    Your Name*

    Date of Birth*

    Your email*

    Mobile phone*

    Home phone

    What is your main reason for seeking a consultation?

    How long have you had this pain/complaint?

    How would you rate the pain out of 10 (0 being no pain, 10 being worst pain imaginable)

    GP details

    Technology requirements - Do you have access to any of the following (please tick all that apply)

    Computer, tablet or smartphone capable of video calling (microphone and camera)Internet - good connection/speedInternet - poor connection/speedPhoneEmail

    How did you hear about us?

    Friend/familySearch engineSocial mediaWorkOther

    Consent

    1. PURPOSE: The purpose of this form is to gain your consent to participate in a virtual consultation.
    2. NATURE OF CONSULTATION:
    a. The consultation will include a thorough history of your complaint as well as relevant medical history
    b. You may be required to undergo some sort of examination or guided self examination
    c. You will receive self management advice including but not limited to exercises, pain relief strategies, goal setting and reassurance. If onward referral is necessary your chiropractor will discuss this with you
    d. Video and audio recordings may be taken during your consultation. These will be handled in accordance with GDPR regulations and current rules surrounding storage of medical records
    3. CONFIDENTIALITY: All reasonable and appropriate efforts have been made to eliminate any risk of breach of confidentiality when carrying out virtual consultations and all existing confidentiality protections also apply to virtual consultations.
    4. RIGHTS: You may withhold or withdraw consent to virtual consultations at any time.
    5. RISKS, CONSEQUENCES AND BENEFITS: Virtual consultations and the advice contained within them can be effective ways of managing complaints of musculoskeletal pain and other related musculoskeletal conditions. Whilst the risks of serious adverse events with this sort of management are extremely low, there are risks associated with exercise and self management of pain. The most common of these is an increase in pain following exercise. This is perfectly normal and will usually subside within a few days at most. For further information about the risks and benefits of this sort of treatment please contact the clinics on admin@dixon-health.co.uk