Physiotherapy Treatment Application & Consent · Haritha Santhanam Physiotherapy Centre

Applicant details

Full name (as in ID) *

Name in Malayalam / Hindi

Date of birth *

Gender *

Mobile number *

WhatsApp number (if different)

Email

House name / address *

District *

Panchayat / municipality & ward *

PIN code *

Social & eligibility information

Annual family income *

Number of family members

Occupation

Medical information

Diagnosis / reason for referral *

Referring doctor *

Hospital / clinic

How long have you had this condition?

Received physiotherapy before?

Yes No

Other medical conditions (diabetes, hypertension, heart disease, etc.)

Current medicines

Allergies

Mobility aid used

Preferred therapist

Required documents

Recommendation letter from ward member / local-body representative *

PDF or photo, max 10 MB

Doctor’s prescription / referral *

PDF or photo, max 10 MB

Medical reports / scans (optional)

Emergency contact & guardian

Emergency contact name *

Emergency contact phone *

Relationship

Parent / guardian name (for children under 18)

Guardian relationship

How did you hear about us?

Consent & declaration

PRIVACY NOTICE & CONSENT (Digital Personal Data Protection Act, 2023) 1. Who we are: the clinic run by the charitable society named on this page is the Data Fiduciary for the information you give. 2. What we collect: your name, contact details, date of birth, gender, address, the last 4 digits of your Aadhaar and your ABHA number (optional), family income and ration-card category, your medical history, prescriptions, reports, recommendation letter, photos/videos you choose to share, and your signature. 3. Why: to assess eligibility for charitable treatment, to provide and record physiotherapy care, to book appointments and send reminders by WhatsApp, SMS or email, to report to the society's committee and donors in anonymised form, and to meet legal duties. 4. Sharing: only with the clinic's committee, clinicians and staff who need it, with service providers who host the system or send messages for us, and with authorities where the law requires. 5. Retention: treatment records are kept for as long as medical-record rules require; other data is deleted when no longer needed for these purposes. 6. Your rights: you may ask to see, correct, update or erase your data, withdraw consent at any time (this may end charitable treatment), and nominate a person to exercise your rights. Contact the Grievance Officer shown at the clinic or on this website; we reply within 90 days. You may also complain to the Data Protection Board of India. 7. Treatment consent: I consent to physiotherapy assessment and treatment by the clinic's registered therapists, including examination, exercise, manual therapy and electrotherapy as clinically indicated. I understand sessions are approved by the Management Committee and further sessions need new approval, and I will inform the clinic at least 12 hours before a missed appointment. 8. For a child or a person with a disability, this form is completed and signed by the parent or lawful guardian. I confirm the information is true and I give consent for the purposes above.

I have read and agree to the consent and declaration above.

Signature *

Sign in the box using your finger or mouse.