Home Physiotherapy

Name

Email

Phone

Age

Gender
—Please choose an option—MaleFemale

Arthritis Condition / Mobility Issue

How did you learn about the NAF Home Physiotherapy Programme

Attach photo of NRIC (maximum 2mb, .jpg, .png, and .pdf only) (Required)

Attach photo of CHAS card or screenshot CHAS card from Singpass app: (maximum 2mb, .jpg, .png, and .pdf only)

Attach doctor’s memo/diagnosis of condition: (maximum 2mb, .jpg, .png, and .pdf only) (Required)

Other attachments (eg. Pioneer card) (maximum 2mb, .jpg, .png, .pdf only)

Provide a brief description of any underlying health conditions that the therapist should be made aware of (eg. cardiovascular, respiratory, metabolic, pregnancy or other relevant conditions)

Acceptance and Indemnity

I hereby declare that:

1. I do not have any infectious diseases and am fit to receive home physiotherapy services. I agree to inform NAF immediately if there is any change in my health status or if I am diagnosed with an infectious disease prior to receiving the home physiotherapy services.

2. I understand that NAF engages third party service providers ("therapists") to provide the home physiotherapy services. NAF and/or the therapists can terminate the home physiotherapy service at their sole discretion, either before or during the physiotherapy sessions.

3. I acknowledge that I can only pre-book appointments for 2 sessions. Subsequent appointments can be made with NAF upon therapist's recommendation and/or diagnosis of the patient.

4. I agree to indemnify NAF, its employees, and therapists from any and all claims, liabilities, damages, and expenses arising from or related to the provision of home physiotherapy services.

5. I acknowledge that NAF shall not be liable for any loss, injury, or damage suffered by me because of the home physiotherapy services provided, except where such loss, injury, or damage is due to the gross negligence or wilful misconduct of the therapists.

6. By providing the information set out in this form, I consent to NAF and their representatives and/or agents collecting, using and disclosing my personal data to provide me with physiotherapy services and other reasonably related purposes. Such purposes are set out in the NAF Data Protection Policy or available on request.

I agree to receiving marketing messages via SMS, telephone call and other Singapore phone number-based messaging, regardless of my registration with the Do-Not-Call registry. I understand that I may withdraw such consent at any time via unsubscribe facilities or by email to NAF at info@naf.org.sg.

NAF's Home Physiotherapy service is in its pilot phase till 31 Dec 2024. NAF reserves the right to make changes to this programme at any time during or after the pilot phase.