New Patient Consultation Form - Lloyd's Wellbeing Centre

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020 7327 5341

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Lloyd's Wellbeing Centre

Supporting health, fitness and wellbeing in the Lloyd's community

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Clinic Services
Classes
Employee Wellbeing
Medical Consultants
Lunchtime Talks
Blog
BOOK ONLINE

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New Patient Consultation Form

New Patient Consultation Form

Please take the time to fill in this form accurately and completely.

Personal Details
Name*
Mr/Ms First name Last name
Date of Birth*
Address*
Address Line 1 Address Line 2 City Postcode
Phone*
Email*
Employer
Are you a Lloyd's Pass holder?*
- Yes
- No
Marketing Consent
We would like to keep you updated with news, events and offers from the Lloyd’s Wellbeing Centre. Please tick below if you consent to us using your details for marketing purposes. (We don’t pass your details on to any other companies, and you are able to unsubscribe from our marketing at any time.)
Sign me up for personalised news and promotions
- Yes
Private Medical Insurance Details (if applicable)
Do you have Private Medical Insurance (PMI)?*
- Yes
- No
Insurance Provider*
Membership Number
Authorisation Number
Policy Anniversary Date
Excess Amount for the policy
Medical History
Are you attending or receiving treatment from a Doctor/Therapist?*
How would you describe your general health?*
Has a doctor ever diagnosed you with...?
- Thyroid problems
- Heart problems
- Rheumatoid arthritis
- Epilepsy
- Asthma
- Diabetes
- Osteoporosis
- Allergies
- Chronic hypertension
- Lung or Liver disorder
- Severe Anaemia
- ME, MS or IBS
Do you, or could you be...?
- I am/could be pregnant.
- I smoke.
- I take prescription medication.
- I have a personal history of cancer.
- I have had an infection requiring antibiotics recently.
- I have had broken bones and/or major surgery.
Further Details on any of the above (if applicable)
How did you hear about us?
The main way that you heard of the Lloyd's Wellbeing Centre*
- Google / internet search
- Email Marketing
- Friend or Colleague
- Promotional event
- Flier or Leaflet
- Insurance Company Referral
- Other
Privacy Policy
The Lloyd's Wellbeing Centre is committed to protecting your personal data. It will be processed in accordance with our Privacy Policy which can be found at www.lloydswellbeingcentre.co.uk/privacy-policy.
Rescheduling or Cancelling Your Appointment
I understand the clinic operates a 24-hour cancellation policy, and I will be charged £30 for a cancelled, rescheduled or missed appointment where less than 24-hours notice is given. (There is no charge for an appointment that is cancelled or rescheduled with more than 24-hours notice.)
Informed Consent and Indemnity Agreement
I confirm my details are correct and that I have not withheld any information that may be pertinent to my treatment. I confirm that I/my insurance authorisation will cover the cost of any treatment and that I am liable for any excess on my policy (if applicable). I agree to pay all amounts due upon request. I consent to receiving treatment on this and any subsequent occasion in the future, and understand the results are not guaranteed. Benefits and risks associated with treatments will be discussed with each patient on an individual case by case basis. I wish to rely on the Practitioner to exercise judgement during the course of the treatment, which they feel at the time based upon the facts then known, is in my best interests.
ADDITIONAL INDEMNITY FOR CUPPING AND ACUPUNCTURE: I understand that Cupping and Acupuncture treatment can cause temporary localised discolouration and/or bruising. This can remain visible for a number of days, especially in the case of Cupping treatment.
Do you confirm your agreement?*
- I have read the above terms and agree to these conditions.
Tick the box above if you agree to these terms and wish to use Lloyd's Wellbeing Centre services provided by Thrive4Life Limited.
Name
This field is for validation purposes and should be left unchanged.

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THE LLOYD’S WELLBEING CENTRE

We provide a wide range of physical therapy and wellbeing services in the City of London.

Lloyd’s Building, Upper Basement
1 Lime Street, London, EC3M 7HA
020 7327 5341 | info@lloydswellbeingcentre.co.uk

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LOOKING FOR A NURSE OR DOCTOR?

The Nurse Service is provided by HCA Healthcare:
0345 437 0691 | appointments@hcaprimarycare.co.uk

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Wellbeing services are provided by Thrive4Life Limited. | View our Privacy Policy.

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