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Putney New Client Online Assessment - 1

Health History

Our practice is designed to help you achieve optimal health and vitality.

Please take your time to fill in the following information in detail. This 6 page assessment generally takes 10 to 15 minutes to complete.

Mobile users may find the experience difficult so we suggest using alternative means.

Completing this ensures we have all the information we require prior to you attending to assess, evaluate and care for you properly.
Some questions may seem slightly odd but they are important to help assess your overall health and well being.

Unfortunately in the event your assessment isn't completed prior to attendance It is unlikely we will be able to care for you properly and you will be asked to reschedule your appointment.

If you experience any difficulties completing this, please do not hesitate to get in touch on 02087856144.
Personal Details *This question is required.
Marital status
Children names and ages? (if relevant)
How did you find us? *This question is required.
Do you have health insurance that may cover some of the cost of chiropractic care? *This question is required.
Is your provider: *This question is required.
Please name your insurer for our records in the event they contact us.

Please be advised that we do not invoice insurers directly. All accounts must be settled on the day of consultation and we will gladly issue you a receipt so you may claim back any entitlements yourself.
Dr Craig (30020809) Dr Luke and Dr Bryan (30047114) are BUPA registered.
Please ensure your account is linked to the correct provider code to avoid any further out of pocket administrative fees being incurred.

Unfortunately Dr Ami-Bree and Dr Samantha Kale are unable to accept BUPA clients at this time. In the event you wish to use your insurance, you will need to see an alternate practitioner.

To invoice BUPA UK directly on your behalf, we require the following information. We unfortunately cannot facilitate invoicing in this manner with a BUPA international or corporate account.

While BUPA may issue a code valid for (X) amount of sessions, it is our experience that this does not necessarily mean that they will cover the cost of that many sessions. Please clarify this with your insurer to avoid any potential financial shortpayments that you may not have been expecting. It may save you money to continue privately.

Please be advised that failure to provide all relevant information may result in additional out of pocket administrative fees being paid directly to Putney Chiropractic for setting up your account. This includes ensuring that your authorization code is linked to your practitioners provider code listed above.  

You will also be required to sign a terms of business at your visit and provide details of a valid card to be processed in the event of any short payments from BUPA to Putney Chiropractic.

  *This question is required.
Have you received chiropractic care in the past?
Please inform us of your previous care where you can: