New ClientsPlease complete the form below Name * First Name Last Name Contact Phone Number * Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Name of your GP / Surgery * Doctor’s Surgery Telephone No. * Do you suffer (or have you ever) from any of the following? Please click on any boxes that apply or check 'Not Applicable" * Not Applicable Thyroid problems Heart Conditions Rheumatoid Arthiritis Epilepsy Asthma or other Respiratory conditions Diabetes Steroid Use Blood Pressure Issues Skin Infections/Conditions Stroke Thrombosis Cancer Surgery (recent & past) Digestive Problems Headaches Allergy Anxiety Depression Are you going through the menopause? * Are you pregnant? If so, how many weeks? * Please give details of any of the above including regular medication you are taking? * Is there anything else about your health and wellbeing that you would like to tell me? * In a few words, please tell me the reason for booking your appointment? * Declaration and Informed Consent * This information I have given in this form is honest, accurate and correct to the best of my knowledge. I have been given the opportunity to ask all the questions about its content, and all of my questions have been answered to my satisfaction. I appreciate that although all reasonable steps to reduce risk of infections have been taken, including screening potential Covid-19 cases and undertaking increased hygiene and distancing protocols there may still be a risks of infection from a face-to-face appointment. I knowingly and willing consent for face-to-face appointment to take place. By clicking YES below, you (the client) agree with the following: • Written consent must be given by me prior to any disclosure or sharing of my personal and clinical information with any third party. • All massage treatments, information and records will be kept confidential and securely stored for use only by massage therapist • The information I have provided on the attached client detail form is true and correct. • Privacy will be assured as I have the right to undress only to my comfort level and according to the requirements of the treatment. • Draping will be used by the therapist as required to expose only those parts of my body that require treatment and/or as I choose to ensure my comfort during treatment. • If at any time during the treatment I feel uncomfortable with the treatment for any reason, I have the right to request an immediate stop to the session or request modification to the treatment, regardless of prior consent given. • Promptness is expected for all appointments. In the event of lateness, the massage may be cut short due to other commitments of the therapist. • Fees will be maintained per the schedule. • Cancellation of any appointment must be received at least 24 hours in advance otherwise 50% of the appointment fee is due. • Fees for treatment are due prior to departure on the day of treatment. Cash, EFT & Credit Cards are accepted. • The therapist may refuse to treat any client or part of their body with just and reasonable cause. Have you read and understood the information above and consent to the massage treatment for the condition you present to your therapist? Please select YES or NO from the dropdown below. YES NO Data Protection Policy * The clinic fully complies with the most up to date Data Protection Policy and has a transparent approach to Data Processing which empowers individuals to know about the collection and use of their personal data. We collect data for ensuring we have the right information for assessing your suitability to treatment, for completing the appropriate treatment, for contacting you regarding appointment follow-ups and for a referral to GP or other healthcare practitioners if deemed necessary. Your data may be viewed by clinic staff to ensure continuity of care is given and for standards clinic running purposes. In addition, the data may also be shared with NHS Trace and Test if required to minimise the spread of Covid-19. We collect only data that is relevant to those purposes and we keep it for 7 years. All information held will be treated as strictly confidential and will only be released to any other external party with the consent of the client. I have read The Clinic’s Data Protection Policy and consent to The Clinic processing records as outlined above and understand that I can withdraw my consent on the processing of data at any time. Thank you for completing this form.
