Holistic Therapies Medical History and Consent Form | Webform Portal

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Medical History and Consent Form

Client Details

Name: *

Date of Birth: *

Contact Number: *

Email: *

Address: *

Postcode: *

Emergency Contact

Emergency Contact Name: *

Emergency Contact Phone: *

Relationship to you: *

Medical History

Are you currently taking any medication or supplements? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Do you have any medical conditions? *

Please list: *

Do you have any current injuries or previous injuries that still affect you? *

Please list: *

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Consent

I have, following consultation, consideration and discussion, agreed to undergo this therapy.

I am fully aware that the services I wish to receive are those of a holistic nature and do not serve as a substitute for professional medical advice, examination, diagnosis or treatment.

I have had the procedure explained to me and understand the nature of the treatment.

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 lifestyle, ongoing medication and general health.

I understand that if I 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.

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.

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