PROM COUNTRY OSTEO

Your contact details

Emergency contact

GP details


Government support

Communication


Lifestyle factors

Including exercise, hobbies, etc.

Your complaint/injury


In this section please complete details ONLY about your main complaint/injury. There is a section later in the form for other complaints, if present.

Please provide similar depth of detail to above.

Medical information

Including tapes, creams etc.

Female patients only section


Consent to Osteopathic care

Please tick if you understand and accept the following:


1. Osteopathy is generally considered a safe form of health service.

2. However, we need to make you are aware of the risks associated with an osteopathic consult before deciding to receive it.

3. Osteopaths are trained health-professionals. We use our best clinical judgement to limit foreseeable risk to patients from treatment and openly discuss these risks.

4. There is risk associated with the examination, treatment & management we provide. Risk is relative to your individual circumstances & your particular consult.

Common risks to treatment include, but is not limited to: 

  • Aggravation/making an injury worse

  •  Soreness

  • Feeling tired, fatigued

  • Numbness or tingling

  • Headache

 Serious risks to treatment are incredibly rare. There is a lack of evidence to conclude figures. Despite the rarity, these risks are believed to exist. Therefore, we need to make you aware of them. 

They include: 

  • Fracture/broken bones

  • Nerve root or spinal cord injury

  • Pneumothorax (punctured lung)

  • Worsening of disc herniations 

  • Stroke & arterial dissections


Please type and electronically sign to accept terms outlined above: 

* If you are under the age of 18, we may require a parent or guardian to sign on your behalf

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