Patient Registration – Posture Assessment

Thank you for choosing active X backs. I’m delighted to welcome you. Our aim is to provide you with an accurate assessment of your posture and guidance on how to improve it. If you have any questions or concerns, please don’t hesitate to contact me at gavin@active-x.co.uk or on 0131 221 1415.

Please bring shorts to the appointment to wear during the assessment. In order to conduct a full postural assessment we will need to take two pictures of you in shorts and bare top (men) / bra or “boob tube” (women) – or you may wear a vest and roll it up to show your abdomen. This is so that we can see tops of shoulders, belly button, front of hip bones, knees and ankles.

Thank you very much for taking the time to register online. The below form is confidential and all information will be held in the strictest confidence by active X backs. Please fill in all appropriate fields as this information helps us greatly to manage your health and to run our business efficiently in order to deliver the best service possible. If you’re unable to register online prior to your first appointment, please arrive at the clinic ten minutes early in order to complete the form then.

We look forward to helping you to be active for life.

Warm regards,

Gavin Routledge
Clinic Director

If you are human, leave this field blank.

CONTACT DETAILS

Title * Mr Mrs Miss Ms Doctor Prof Other

First name *

Last name *

Gender * Male Female

Date of birth *

Address *

Including postcode

Home phone number

Work phone number

Mobile phone number

Email address *

A BIT MORE ABOUT YOU

Occupation

If applicable

Employer/Company Name

How did you hear about active X backs? * Recommendation Passing by Web search Flyer G.P. Yellow Pages Sponsorship Programme Other

If you answered Recommendation above, who recommended you?

If you answered Other above, please give details.

Do you consent to us contacting your G.P. if necessary? * Yes No

If Yes above, please enter your G.P.'s name, practice and address below.

We occasionally send health newsletters and offers via email (low volume so not to bombard you) - would you like to receive these? You can unsubscribe at any time you choose. * Yes No

CLINICAL

What prompted you to book a posture assessment? (e.g. back or other pain, recent change in your posture) *

Have you had back surgery in the last 2 years? If yes, please give details. *

Which of the following would you like? *

Relief Prevention Relief & Prevention

DATA PROTECTION AND PRIVACY OF DIGITAL IMAGES

For your safety and security, active X backs undertakes to:
- Store all images taken of you for the Posture Assessment solely on the hard drive of one PC.
- Delete images from our digital camera as soon as these images have been transferred to the PC.
- Ensure that the PC storing data will be password protected at all times.
- Ensure that no images will be downloaded from the PC other than for the production of reports solely for the patient concerned and that no copies of these reports will be made except with your express written consent.
- Ensure that the PC is part of a network protected by a physical firewall.
- Comply with the Data Protection Act.

CONFIRMATION & CONSENT

Do you consent to active X backs handling digital images in the manner as outlined above? *

Yes No

Do you confirm that you have completed all requested information fully and correctly and accept our terms as stated above? *

Yes No

Do you consent to this consultation, assessment and any ongoing treatment? *

Yes No

Do you consent to us sharing your clinical notes with other active X clinicians? *

Yes No

Today's date *

By submitting this form you are certifying that your answers are correct and confirming that you accept our terms as set out above.