Sports and Holistic Therapies Health Questionnaire and Consent Form | Webform Portal

Health / Sports Questionnaire and Consent Form

All information is strictly confidential.

Name: *

Mobile: *

Home Tel:

E-mail: *

Address:

Post Code:

Date of Birth:

Is this a Wellbeing treatment, Yes or No

If No, then please give full detail below

Do any of these health conditions apply to you?

If yes, please give details:

If in Pain, please rate pain scale1-10:

Do you Smoke? If yes, How many per day:

Do you have a Hernia? If yes, what type:

Are you receiving any alternative therapy

If yes, please give details:

I will immediately inform my therapist/practitioner/trainer of any changes to my medical status.

Consent

I have, following consultation, consideration and discussion, agree to undergo some or all of the following therapies:Holistic or Sports massage, Dry Needling, Dry Myofascial Cupping, Joint Mobilisation, Heat Therapy, based on the experience and knowledge of my therapist. I am fully aware that none of the above serves as a substitute for professional medical advice, examination, diagnosis or treatment.

I understand the information I have given to be the correct and give my consent below

I will have the procedure fully explained to me by my therapist . I fully understand this treatment is not a substitute for medical treatment and it may take several sessions before I notice any benefit. This will depend on my life style, ongoing medication and general health.

I understand that if I have been untruthful with my details or have failed to give enough relevant information the outcome of any therapy/treatment/class could be adversely affected and my health and well-being may be put at risk.

I understand the therapist/practitioner/trainer does not claim to cure or to diagnose any medical condition in the same way as a doctor/physician. Their opinion is that of a holistic, complementary and alternative therapist and their professional opinions, advice, examinations and recommendations do NOT constitute the medical advice of a doctor/physician.

I confirm that I have given my personal details for the therapist’s/practitioner’s/teacher’s use in connection with the therapy/treatment/class and consent to the storage of these details for at least ten years. (We are unable to provide any therapy/treatment/class without your consent.)

I confirm that you may retain this information so that you can contact me again in the future.

I understand that open/group activities may be recorded and any material collected may be shown on Social Media pages such as Facebook

Cancellation Policy. We value your business and ask that you respect our business scheduling policies, Please notify us at least 24 hours in advance of any cancellation. Any cancellations with less than 24 hours notice are subject to a cancellation fee amounting to the cost of the scheduled treatment. Thank you for understanding that out time is important. I have read and understand the above statement.

Client Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

Covid-19 Policy.

Changes may be made to the advertised treatment depending on prevailing circumstances. If paying cash for your treatment,please bring the correct anount in a sealed envelope.

On the morning of your treatment please phone me if you are feeling inwell or showing covid-19 symptoms or you have been in contact with someone who is showing signs, as I will be unable to treat you.