T2C/BM Consultation Form

Client Consultation Form

Please complete the details below, this form will then be stored in accordance with GDPR Regulations.

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Moblie or phone number

Emergency contact number and name

GP Surgery/Name

Email*

example@example.com

I give permission for T2C and the HHTC to add me to their mailing list*

YesNo

Occupation

List all medications or supplements you currently take along with lifestyle habits:

Referred by

Reason for Consultation

Please list any injuries you may have

Have you seen your GP for this condition

If Yes please give details

What service do you require

Please check if any apply to you.

If you have ticked any of the above please give details

None of the above listed medical conditions apply to myself*

T2C/Body Mechanics involves many different types of physical evaluation and treatment which may include mobilisation, soft tissue massage, assisted stretching, manual therapy, exercise, Reiki and MLD as with all forms of treatment, there are benefits and risks involved treatment. The physical response to treatment varies and cannot always be predicted as every individual is different. During your visit, some of the treatments may involve exposing and touching the area in need of treatment. Every effort is made to preserve modesty and keep you comfortable. Please communicate to your therapist if you have any concerns during the treatment. I understand that the T2C/BM massage is provided for the relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that T2C/BM massage should not be construed as a substitute for medical diagnosis. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile during future sessions and understand that there shall be no liability on the therapist part should I fail to do so. By signing this, I hereby consent to Alison Young T2C/Body Mechanics evaluation and treatment as deemed appropriate. I have the right to decline treatment at any time. I have also been given information on the GDPR data regulations and agree for AY T2C Bodymechanics and the HHTC to email myself by adding to the mailing list.

Therapist I will explain your treatment and discuss treatment recommendations with you. T2C and Body Mechanics therapy is the most effective if you participate according to the treatment plan agreed upon. If at any time you have questions regarding treatment and services provided, please do not hesitate to talk to me and I look forward to helping you.

I have read the disclaimer and confirm consent for treatment.*

YesNo

Signature*

Date*

Date