Physio West Registration

Physio West Registration

About Physio West

Thank you for your interest in Physio West. Our programmes are made possible by funding from the HSE. They are available to all people with MS living in Galway, Mayo or Roscommon. You do not need to be a member of MS Ireland to participate.

How does Physio West differ from the MS Ireland's other regional programmes?

In the Western region we have a directly employed physiotherapist, who is specialist in MS and other neurological conditions. The physiotherapist is supported by physiotherapy assistants to help deliver your care. This means that the physiotherapist is able to deliver specialist care to more people with MS.

How is my information managed?

This form will help us learn about you and what you would like to gain from a programme. Your information is input directly into MS Ireland's SalesForce systems and is only available to the physiotherapists and administrators that delivers Physio West. You can decide against integrating your information with MS Ireland's membership database if you wish. To avoid unnecessary duplication within our database, your name email and date of birth only will be visible to all MSIreland staff. If you are already a member of MSIreland, your regional office will be able to see that you are taking part in Physio West. They will not be able to see the information you enter.

To help us find the programme that best matches your needs, please provide enter the following details

Your First Name

Your Surname

Preferred Phone

Mobile PhoneFixed-line Phone

Phone

Mobile Phone

Email Address

Age

Name of referrer

Name and email address of referrer

Are you a member of MS Ireland or do you avail of support from a branch or region?

YesNo

Would you like to be added to MS Ireland's members database?

YesNo

Which branch or region?

Do you use a walking aid?

YesNo

Have you had a fall recently?

YesNo

Have you had any near misses, or almost fall, or catch yourself before you fall?

YesNo

GDPR and Consent - In order for Physio West to comply with current General Data Protection Regulations (GDPR) we are required to obtain your formal consent to gather and use information about you. Under this regulation Physio West and MS Ireland must adhere to the following:

· Valid consent must be explicit for the data collected and the purposes the data is used for

· The consent does not imply consent forever

· The data must only be used for the purpose it was initially intended for and no other

The first part of the data we collect will be used to ensure your safety and suitability to participate in Physio West. (Medical history, Medication list and Physical Activity Readiness Questionnaire). This data will be collected over the Zoom assessment or in person and is stored on our secure online servers and encrypted laptops.

The other data we gather will be during an in-person discussion or an individual consultation using Zoom for healthcare as well as an initial assessment on Form Assembly. The questionnaires and information gathered will be used to evaluate the effects of the programme or to tailor the programme for you. You will complete the same questionnaires before and after the programme. We will also record information about how you are completing the programmes.

Your data will be stored in secure offices or on encrypted laptops for the duration of the programme and for 7 years afterwards . Only the Physio West team will have access to your individual data.

The data in the questionnaires you complete before and after the programmes will be entered into spreadsheets and analysed as group averages with no sharing of individual data. The aggregated (and hence anonymous) data from all participants will be used in project reports or in presentations to professional groups or to health funders. We may ask if we can use your information for a case study and you can choose if this is anonymous.

Therefore, Physio West requires you to consent to the following:

I consent to the Physio West team collecting, processing, analysing, and storing the data associated with providing me with an exercise programme or treatment

I consent to the Physio West team creating and updating a file with my data

I consent to be assessed and treated by the physiotherapist or exercise personnel either in-person or using Zoom for healthcare

Yes - I consent to the GDPR policy outlined aboveYes - I am a healthcare professional/MSIreland staff member referring a person who has given their verbal consent for me to complete this form on their behalfNo - I do not consent to the GDPR policy outlined above

Thank you for completing this form which will be reviewed shortly by the Western Region Physiotherapy service team.

If you have queries please contact either; Mary: Marybu@ms-society.ie 086-777-7281

Susan: SusanC@ms-society.ie 086-036-4109

Jack: JackM@ms-society.ie 086-074-9628

If you have any special requirements, concerns or requests, you may note them below:

Contact Information