A carefully selected, managed network of handpicked Chartered Physiotherapists

Our carefully selected, managed network consists entirely of handpicked Chartered Physiotherapists and established clinics that offer a professional and friendly approach to patient care with a high emphasis on manual therapy.

The Physiotherapists within our network benefit from receiving high quality, triaged referrals and the opportunity to work with some of the UK's largest and most prestigious organisations.

We are always keen to hear from Chartered Physiotherapists who feel they would be a valuable addition to our network. If this sounds like you, then we look forward to receiving the completed registration form below and copies of your relevant insurance documentation.

If you have any further questions please do not hesitate to contact one of the team.

* Mandatory Information

New Practice Application Form

Practice Name: *

Address Line: *

County: *

Post Code: *

Practice Contact Details

Telephone: *

Fax:

Email: *

Primary Contact(s) for Clinic

1st Contact Name:

1st Contact Position:

2nd Contact Name:

2nd Contact Position:

Practice Details

How many Physios do you have?

Full Time:

Part Time:

Male:

Female:

What are your opening hours?

Monday:

Tuesday:

Wednesday:

Thursday:

Friday

Additional required information

How many locations do you have?

What % of capacity are you running at?

Do you have a full time receptionist?

Do you have parking facilities?

How long have you been established?

Do you have access to Microsoft Word?

What is your cancellation policy?

Who should cheques be made payable to?

Please include a short description of your practice:

Insurance Policies

Do you have public liability insurance?

Do you have employee liability insurance?

Treatment Information

How many treatment rooms do you have?

What is the minimum time allocated to each treatment?

What are your treatment costs?

Initial assesment (in £):

Subsequent treatments (in £):

Practitioners

You have not yet added any practioners, please use the practioner details section below to add your practioners.

Practitioner Details

Please detail each of your practitioners below:

Name of practitioner:

CSP Number:

HPC Number:

Is the practitioner a member of OCPPP?

Date of qualifying (DD/MM/YYYY):

How many years has the practitioner been practicing?

Please list any areas of specialisation:

Is the practitioner able to offer domiciliary visits?

On average, what % of the practitioners treatments are performed manually:

Is the practitioner BUPA registered?

Does the practitioner maintain their CPD requirements?

Optional Pictures

Please upload practice picture:

Please upload 2nd practice picture:

Please upload 3rd practice picture:

Declaration

I wish to apply for membership to Physio Med provider Network. The information I have supplied on this application form is accurate and correct.

I would like to register to receive referrals through the Physio Med Provider Referral Programme and will forward a copy of my proof of insurance's.

I have read and agree to the Business Terms and Conditions. I understand that by submitting this form I am not under any obligation to accept referrals.

Agree: *

Disagree:

Get in Touch

For more info, call us on:

0113 229 1300

or email: Customer Services

Case Studies

Read success stories from existing Physio Med clients.