Associate Network Clinic Self-Audit Form

Join our network!

FitBack Physiotherapy are a leading provider of specialist Occupational Health Physiotherapy and Health and Wellbeing services to some of the UK`s leading brands.

Due to expansion, we are growing our network of associate private physiotherapy clinics across the UK. We are looking for outstanding clinics interested in receiving Occupational health physiotherapy referrals to join our growing national network.

Our patient base are employees that are either absent from work due to MSK issues or suffering with MSK issues affecting their work. Our physiotherapy interventions are work focused with an aim to returning patients back to work or full duties as quickly and safely as possible. Our associate clinics will be providing employees with treatment when they really need it which isn’t always accessible through traditional pathways.

We differ from other Physiotherapy network providers in that we don’t receive referrals from insurance companies for low level claim whiplash disorders. Furthermore, we believe our payment terms and conditions are amongst the best of the network providers.

We invite you to join our network and look forward to welcoming you on board!

Instructions (Please Allow 20-30 minutes to complete)

  • Please note this document is based on CSP clinical quality assurance standards audit minimum recommendations.
  • Please do not refresh your browser or leave the page before submitting otherwise your data will be lost.
  • Before completing please read through this document to ensure you have all the documentation that is necessary.
  • Please ensure that all sections are fully completed.
  • Please ensure that all documents requested are attached when submitting the form.
  • Following submission of your application and if successful, FitBack will contact you with payment terms and conditions.
  • If you have any queries prior to filling in the form please email FitBack at clinics@fitback.co.uk
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  • Clinic Details

    Please complete the following questions below:

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    Please list your clinic opening hours below:

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    Open
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    Further clinic information needed:

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    Please select the specialities provided by the clinic:

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    Save & Continue

    Clinician Details

    Please list all the clinicians working within the clinic below:

    Please note that without clinician details they will not be able to assess/treat FitBack patients.
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    Add Clinician
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    Update Clinician Delete Clinician

    Save & Continue to the next section
  • Policies and Procedures Checklist

    Please note you don't need to reply 'yes' to all these questions to be accepted.

    Is there an organisational policy for the following:

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    Are there policies for:

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    Save & Continue to the next section
  • Clinical Governance

    Is there a clinical audit programme to ensure continuous improvement of clinical quality, with clear arrangements for ensuring that clinical audit monitors the implementation of clinical effectiveness which includes:

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    Is there a clear and responsive procedure for making and dealing with complaints including policies in place which ensure:

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    Save & Continue

    Record Keeping

    Please confirm that within the last 3 months you have audited a minimum of 3 sets of patients notes in line with section 6 (Record Keeping and Clinical Governance) of the CSP Quality assurance standards

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    If no please add comments

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    Save & Continue to the next section
  • Documents for Upload

    Please upload the following documents:

    Each file must be no larger than 20MB and must be one of the following file formats: jpg, jpeg, gif, bmp, png, docx, doc, pdf, key, ppt, odt, xls, xlsx, csv, txt
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    Upload file
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    Please send a photo of the front of your clinic and a photo of your clinic room to clinics@fitback.co.uk following submission of your application.

    If a sole practitioner, I can confirm that I have a continuity plan should I be unable to work:



    If no please add comments

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    Save & Continue to the next section
  • Declaration

    I hereby declare that the details provided above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.

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  • Congratulations, your application has been submitted.

    Many thanks for taking the time to complete this audit. Following submission of your completed audit form FitBack will then send contracts and terms and conditions to successful network clinics, along with a form requesting your details for payment.

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