Putney Assessment for Infants & Toddlers

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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 4 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
Child's Details *This question is required.
Calendar
Parents Details *This question is required.
Siblings Names and Ages
Address *This question is required.
Midwife Details

We may require further information regarding your childs care. We thank you kindly for providing these details *This question is required.
How did you find us? *This question is required.
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Do you have health insurance that will contribute to some of the cost of chiropractic care? *This question is required.
Is your provider: *This question is required.
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ONLY Dr Craig (GM01772) and Dr Edwina (EW01341) are registered for you to be able to claim back from AXA PPP.

Please ensure your appointment is booked in with either of them if you wish to try and claim back some of your costs.

Putney Chiropractic will not accept any liability if clients fail to book with the correct practitioner and wish to use their insurance.

Be advised Putney Chiropractic will not invoice your insurer directly under any circumstances. You are required to pay in full and claim back yourself.

Please note we cannot amend invoices or practitioners details if you are booked with the wrong practitioner. Please ensure you clarify this when booking or contact us immediately if you have just noted this.

You are still welcome to see an alternative practitioner; however, you will not be able to claim for this as they are not registered.
Please be advised that we do not invoice insurers directly.

All accounts must be settled on the day of consultation with us and we will gladly issue you a receipt so you may claim back any entitlements yourself.

 
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.

Dr Craig (30020809) Dr Edwina (30033575) Dr Luke (3005085) and Dr Bryan (30047114) are BUPA registered.
Please ensure your account is linked to the practitioner you have booked with to ensure you do not accrue any further out of pocket administrative costs.

Unfortunately Dr Ami-Bree is unable to accept BUPA clients at this time. If your appointment is booked with her and you wish to utilise your insurance please contact the office to rearrange. Putney Chiropractic will accept no responsibility in a clients failure to do this.

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. 

We require 24 hours notice to cancel an appointment or full fees will be payable.

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.
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Have you or your child received Chiropractic care in the past? *This question is required.
Please update us of your previous care where you can *This question is required.