Please fill out the following form to help us understand your physical condition.
Health History
Heart Condition
High / Low Blood Pressure
Stroke or Aneurysm
Pace Maker
Varicose Veins
Bruise easily
other Circulatory condition
Diabetes
Kidney Disease
other Urinary condition
Headaches / Migraines
Dizziness / Fainting
Nausea
Spinal Injury
Head Injury
Epilepsy / other seizures
other Neurological condition
Asthma
Chronic Sinusitis
other Respiratory condition
Irritable Bowel / Colitis
Digestive condition
Skin condition
Joint Dislocation
Bone Fracture
Arthritis
Osteoporosis
Rods / Pins / Plates / Shunts
Implants
Cancer
Hepatitis
HIV
GDPR - The data we collect on you
The personal data we collect will be information relating to your contact details, including name, address, phone numbers and email address. This will be used for appointment confirmations, reminders and cancellations, or if we need to get in touch to rearrange appointments. You can opt out of all emails at any time using the booking system. You can opt in to receive news and updates from us via email.
We will also collect data relating to your treatments with us, which may include information about lifestyle, and any relevant health issues.
This data is shared with your therapist(s) and admin assistant. We will only use your data for the purpose for which it was collected, to enable us to administer treatment and provide a professional service.
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We will retain your data on our secure booking system Wix.com.
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You have the Individual Rights under the Data Protection act 2018
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To be informed about the personal data we hold on you
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To access your personal data
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To object to the processing of your personal data
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Restrict the processing of your personal data
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To rectify your personal data
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To erase your personal data
You can exercise your Individual Rights at any time without charge. However, if your request is considered repetitive, unfounded or excessive a reasonable administration fee can be charged.
We will take all appropriate technical and organisational steps to protect the confidentiality, integrity, availability and authenticity of your data.
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Consent
Please Note: Your appointment time has been reserved for you. In courtesy of your therapist & fellow patients, we ask that you provide us with 24 hours notice of cancellation, or a cancellation fee will be charged. Payment for all treatment, whether private or insured, is ultimately the responsibility of the patient.
I authorise the clinic and its associated therapists to collect my personal and medical information as documented above in order to contact me, and give permission for the clinic to leave messages regarding appointments at any of the contact numbers I have provided above. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
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