Havering Therapy Centre - established 1974
01708 621111 Book an appointment
New patients

Registration & consent forms.

Before your first appointment we ask every new patient to complete a registration and consent form. You can fill it in online and send it straight to us, or download a copy to print and bring with you.

Prefer paper?

Download a form.

Print it, fill it in by hand and bring it to your appointment — or complete it online further down this page.

Physiotherapy & general

For physiotherapy, sports therapy, acupuncture and general clinic appointments.

PDF Word

Podiatry

For podiatry and chiropody appointments, including nail surgery.

PDF Word
Complete on your device

Fill your form in on screen.

Choose the form that matches your appointment, fill it in, and your device will produce a finished copy you can print or save as a PDF. Fields marked * are required.

Your information stays on your own device. This form does not send anything over the internet. Everything you type stays in your browser, and the completed form is produced on your own computer, phone or tablet. Nothing is transmitted to us, or to anyone else, until you choose to hand it in.

This document is for your safety, as well as our information. If you have any questions, please ask your clinician. Thank you for your co-operation.

Your details
G.P. details
Funding your treatment

If you are claiming all or part of your treatment costs from a health insurance policy/insurer, we would advise you to contact your provider in advance to ensure that your treatment is covered, as you may need to be seen/referred by a doctor/consultant prior to your treatment with us.

Medical checklist
Consent

I consent to Physiotherapy/Podiatry assessment and treatment as deemed appropriate by the treating clinician working on behalf of Havering Therapy Centre and I consent to the collection, use, and sharing of any relevant clinical information in providing this service to you.

Throughout your episode of care with us, any questions or concerns you may have about any recommended treatment must be shared with your clinician immediately so they can explain the treatment rationale and/or modify your program appropriately. If at any time you choose not to participate in the course of treatment, please tell your clinician immediately.

Privacy Notice: We take your privacy very seriously and will take all necessary steps to protect your data and sensitive information. We comply with UK GDPR and the Data Protection Act 2018 (as amended by the Data (Use and Access) Act 2025), and all relevant medical confidentiality guidelines. Your confidential medical information will only be disclosed to those involved with your treatment. Full details are in our privacy notice.

Your declaration

By submitting this form you confirm the following:

  • I confirm I have read and understood the content of this consent form
  • I consent to undertake an assessment and recommended treatment (if applicable) by a qualified Physiotherapist or Podiatrist registered with the Health and Care Professions Council.
  • I consent to Havering Therapy Centre storing my personal and medical information, during my referral period and for as long after discharge, as is required by law
  • I consent to Havering Therapy Centre sharing relevant personal & medical information with other clinicians, including my GP (if appropriate)
  • I understand that I am responsible for the cost of my treatment(s) and agree to pay a cancellation fee (£30) if appointments are cancelled within 24 hours of the appointment time, or in the event of non-attendance the full treatment fee.
  • Your treatment may be suspended or terminated if you fail to attend an appointment funded by a third party
  • I understand that I may withdraw my consent at any time, without prejudice
  • I understand that I have the right to access, correct, or request erasure of my personal data, and that I may raise any concerns about how my data is handled with Havering Therapy Centre or, if unresolved, with the Information Commissioner's Office.

This creates a finished copy on your own device — nothing is sent over the internet. You can then print it or save it as a PDF.

Returning your form

How to get it to us.

Once you have your completed form, there are three ways to return it.

Bring it with you

The simplest option. Print your completed form, sign it, and hand it in at reception when you arrive. If you'd rather not print at home, come 10 minutes early and complete a paper copy at the clinic.

Post it

Havering Therapy Centre, 94 North Street, Hornchurch, Essex, RM11 1SR.

Email it to us

You can attach your saved PDF to an email to admin@haveringtherapy.com.

Please note: ordinary email is not fully secure. Because this form contains medical information, we'd generally recommend bringing it in or posting it. If you're comfortable emailing it, that's entirely your choice — and it's worth knowing you can always leave the medical sections blank and complete them with your clinician instead.

Any questions?

We're happy to help.

If you'd rather complete your form at the clinic, or have any questions about it, just give us a call.

Call 01708 621111 Email the clinic