Physiotherapy Self Referral Form

Fees will be payable upon completion of your appointment directly with your clinician.  We accept cash, card, or payment by BACS (we will invoice you directly by email with details).

Different charges apply for patients who are referred through their Private Health Insurance, an Intermediary, their Employer, Solicitor or any other 3rd party and Concession Groups.

** Additional charges: 

• Individual tailored exercise programs via PhysiTrack

• Shockwave Therapy

• Exercise Equipment

• Supports, Braces and Taping 

• Reports or letters for clinical / insurance reasons. 

• Please note -these additional charges may NOT be covered by your Insurance, Employer or Solicitor.

You can pay for your Wellness card® during your appointment to activate your 15% discount for that treatment session.  

For more information on pricing, please visit:  https://www.physiofitwestwales.co.uk/prices-physiofitwestwales

CANCELLATION POLICY

• Physiofit West Wales Ltd requires at least 24 hours cancellation notification via email, text or phone call for Self Funded / Private Health Care appointments. For Personal Injury Claims we require at least 48 hours cancellation notification.

• To cancel an appointment do this directly via the appointment email notification (confirmation/reminder) from Physiofit West Wales Ltd sent to your provided email address.

• Cancellations within 24 hours will be charged 50% of the full consultation cost.  This charge must be settled within 10 days or on the next appointment, whichever is earliest.
  

• Failing to pay the 50% late cancellation fee might jeopardise the option to continue treatment at any time and, if your treatment is part of a Personal Injury Claim, might negatively affect your claim procedure and outcome.

• Physiofit West Wales Ltd will always consider fair reasoning for late cancellation but can request evidence of the reasoning of the late cancellation.

Physiotherapy & Rehab for Self-Employed and Employees of Welsh Small & Medium Sized Businesses (SMEs) funded by the Welsh Government.

You may be entitled to access up to 6 sessions of Physiotherapy and Rehab if you are in work or off work with a neuro-musculoskeletal injury / condition which is affecting your work ability, performance or ability to remain in or return to work.

You access this Welsh Government Scheme via a Self-Referral Process DIRECTLY with the RCS-IWSS following this link: https://rcs-wales.co.uk/en/contact-form-iwss-icw-bcu/ or by ringing 01745 336442.

For further information about this Wellbeing Service please visit: https://rcs-wales.co.uk/en/

If you DO THINK you ARE eligible - Please contact the RCS PRIOR to booking your appointment with us!

** Please note - if you ARE eligible and have already applied or will be applying for funding, we will require confirmation from the RCS prior to booking your first appointment.

Are you a current annual Wellness card® holder? 

For ONLY £15 per annum for your DIGITAL Wellness card® or ONLY £20 per annum for your PRINT + DIGITIAL Wellness card® gain access to exclusive discounts and savings throughout Pembrokeshire!

Here at Physiofit West Wales we are offering you up to a 15% DISCOUNT on Private Initial Assessments & Follow-Up Clinic Consultations with Physiofit West Wales!

Click HERE to buy your discount card NOW!

For more information on the Wellness card® and to see the details of all the great savings on various local health & wellbeing services, please visit www.wellnesscard.co.uk

You will receive an email with your DIGITAL Wellness card® to download to your mobile phone wallet - please show the card as proof of purchase at your appointment.

Please click HERE to purchase your Wellness card®

You will receive an email receipt - this is valid to obtain your 15% discount on ALL your treatment sessions prior to receiving your card in the post.

IMPORTANT!  - complete and sign the form which will be linked within your Initial Consultation confirmation email.

Once your Initial Consultation appointment has been made, you will be sent EMAIL confirmation. 

Please READ the confirmation and complete the linked patient medical questionnaire and consent form PRIOR to your Initial Consultation.

Patient consent is a legally required document for Physiotherapy treatment. Without this form being completed, you may not be able to be seen.

THANK YOU FOR YOUR REFERRAL!

PRIOR TO submitting this form, please double check your main contact number and email address.

We will be in contact with you shortly to arrange a your appointment with one of our Chartered Physiotherapists.

Any questions: 

EMAIL - info@physiofitwestwales.co.uk 

TEL - 01646 693333

WHATSAPP - Jo Sharp (Practice Manager) - 07887 945788

Thank you

Team PhysioFit West Wales

For more information on our Physio-Plan Wellness card Membership 

please visit: https://www.wellnesscard.co.uk

Physiofit West Wales Ltd. is commited to ensuring the security and protection of the personal information that we process, and to provide a compliant and consistent approach to data protection. If you have any questions related to our GDPR compliance, please refer to our Privacy Policy for details or contact our Data Protection Officer on 01636 693333.