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CLIENT consultation form

If you are able to fill out this client consultation form before your first session then it would be much appreciated. If it is not possible then please don't worry at all as we can do this together when we meet. 

Please also take note of my privacy policy, detailing why I need to collect your personal data, as well as how it is processed and protected. I am required to collect this personal data in order to do my job effectively and safely, providing you with the best possible treatment, advice and personalised teaching. I will not share this information with any 3rd party, unless required by the law to do so and do all that I can to keep it secure, at all times. My privacy policy sets this out in more detail.

If you have any questions at all then please do get in touch with me.

I look forward to meeting you.

 

Name *
Name
Date of Birth *
Date of Birth
Please put the name and contact details of your next of kin here
Please put your GP practice details here
Please detail here any other healthcare provider/therapist that you currently see and the specialism that they offer you
If you do suffer with allergies, please can you detail these in the box relating to "Key health symptoms" below
Please detail here information that you feel is relevant for me to know prior to your first treatment
Client Disclaimer *
Please read the following carefully and only click that you agree if you are in full agreement: • I understand that the services offered today are not a substitute for medical care. • I will consult my GP or Consultant before treatment if I have any condition that requires approval for bodywork treatments. It is your responsibility and not that of the therapist to consult your GP or Consultant. • I confirm that I will notify my therapist of all known medical conditions and injuries. • I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. • If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will therefore not hold my therapist responsible for any pain or discomfort I experience during or after the session.
Would you be happy for me, on occasion, to send you information about the services that I offer? You may withdraw this consent at any time, to do so you can let me know by any convenient method, my contact details can be found on my website.