Book Telehealth Appointment Book Telehealth Appointment Please enter your details below and our team will contact you to confirm your suitability, appointment time and payment options Patient Name Date of Birth Mobile Phone Number Email Dominant Hand Right Hand Left Hand Ambidextrous Occupation* Sports or hobbies Device you will use (tick any you can use)* Desktop Computer with camera and sound Laptop Computer with camera and sound Mobile Phone Ipad or Tablet Device Internet Access Broadband via cable on device Broadband over wifi Mobile Phone network Physiotherapy QuestionsPlease give as much detail as you can to allow our Physiotherapists to give you the best possible careBody part/location of injury or pain* Describe the issue in as much detail as possible*What activities make the pain/problem worse?*What activities make the pain/problem better?*Have you had treatment for this issue?* Yes No With:* None Doctor Physiotherapist Exercise Physiologist Specialist Xray/MRI/CT Scan/Ultrasound (tick any that apply* Xray Ultrasound MRI CT Scan What was the name of the radiology place* Medical History - injuries, medical conditions and diagnoses you have had*Current Medications*ConsentBy submitting this form you consent to a Kelmscott Physiotherapy team member view you by video camera. No video recordings will take place without your written consent
