Online Consultation Form

Please complete this short questionnaire below prior to your appointment so that your therapist has all of your details.

Name

Email Address

Phone Number

Date of Birth

House Name Number

Street address

Town or City

Postcode

Describe your problem that you are looking for help with

What is it stopping you from doing?

How long has it been going on for?

Do you have any other past medical history (Allergy or Underlying Conditions)?

Do you have any of the following? Do you have any of the following? Bladder Dysfunction History of Cancer Immunosuppression Night pain History of recent trauma Loss of sensation to the area of the bottocks, perineum and inner surfaces of the thighs Lower extremity neurological deficit (numbness or inability to use limbs

Have you had any injuries in the past (even sprained ankles, surgeries etc.)?

Are there any activities or movements that are particularly important to you?

Have you ever attended any form of therapy before (Physio, Chiropractors, Sports Therapists etc.)?

By ticking this box I consent to general T&C's and specifically consent to undertake online assessment and treatment guided by a physiotherapist or chiropractor with Courtyard Clinic By ticking this box I consent to general T&C's and specifically consent to undertake online assessment and treatment guided by a physiotherapist or chiropractor with Courtyard Clinic I Consent

Please write your name in full as a signature

4 + 3 =

What equipment do I need?

All you need is a device with a webcam and microphone so that you can connect over video call. You will also need to be connected to the internet.

Will I need to do anything on the call?

You may be asked to stand up and perform certain movements, and you may be coached through some exercises, we wear suitable clothing.

Do I need to download anything for the call?

You will be sent a link to join the call prior to your appointment. We advise you click that as soon as it arrives and download any relevant software to avoid delays. During the call make sure that you are in a well lit room with as much space as possible.

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Ready to Make a Change?

Making that first appointment is the most important part. If you’re not quite sure what you need don’t worry, give us a call or send an email. Our job is to help you find the best way forward with the most appropriate treatment plan or class for you.

MAKE AN ENQUIRY