New Practice Application

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.

Practice Details

Name

Address

County

Postcode

Telephone

Fax

Email

First contact name

First contact position

Second contact name

Second contact position

Date practice opened

Opening Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Treatment Charges

Initial assessment (in £)

Initial assessment duration

Subsequent treatments (in £)

Subsequent treatment duration

Practitioners

Please note that practitioners need to have more than 4 years MSK experience

Add Practitioner

Additional required information

What % of your treatments are manual therapy? 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

What % of capacity are you running at? 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

How many treatment rooms do you have? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+

Do you have parking facilities? Yes No

Do you have a full time receptionist? Yes No

Do you have disabled access? Yes No

Do you have TM2 or PPS?Please select TM2 PPS Both

If so, do you utilise the online booking?Please select No Yes

Are you BUPA Registered? Yes No

Do you do Domiciliary visits? Yes No

What is your cancellation policy?

Do you have public liability insurance?Please select No Yes

Public liability expiry date

Do you have employee liability insurance?Please select No Yes

Employee liability expiry date

Please include a short description of your practice

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.

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.

* I accept the terms and conditions