Please Note: 

This form will take approximately 10 minutes to complete.

Several consent and policy forms within the intake will require your E-Signature.

Please do not print these forms. Please fill them out online 24 hours before our visit. We are a Paperless Practice utilzing Electronic Health Records.

All information is Confidential. 

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Please mark the date of your Appointment on your calendar. While we make every effort to remind our clients of appointments by email prior to the appointment, it is the client's responsibility to maintain his or her schedule. Missed appointments will be invoiced at full cost. Extenuating circumstances will be reviewed on a case-by-case basis. A strict twenty-four hour (1 full business day) notice via voice mail and email are acceptable. Advance notice allows us to better accommodate our clients on the waiting list. Thank you for your cooperation.

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Privacy of your personal information is an important part of Hands on Health - Family Chiropractor, while providing you with quality health care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information. 

All electronic forms and consent forms are viewed only by Lara Cawthra, chiropractor, unless you have specifically signed a Release of Records to make these forms available to another Health Care Provider or family member.

Our Privacy Policy at Hands on Health-Family Chiropractor outlines what we are doing to ensure that:

• Only necessary information is collected about you;
• We only share your information with your consent;
• Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols;
• Our privacy protocols comply with privacy legislation and standards of our regulatory body, the General Chiropractic Council.

How our Clinic Collects, Uses and Discloses Patients’ Personal Information:

The Clinic / Practice of Lara Cawthra understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how the clinic is using and disclosing your information. 

The clinic will collect, use and disclose information about you for the following purposes: 

• To assess your health concerns
• To provide health care 
• To advise you of treatment options 
• To establish and maintain contact with you 
• To send you newsletters and other information mailings 
• To remind you of upcoming appointments 
• To communicate with other treating health-care providers 
• To allow us to efficiently follow-up for treatment, care and billing 
• To complete claims for insurance purposes 
• To invoice for goods and services 
• To process credit card payments 
• To collect unpaid accounts 
• To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others

By signing this Patient Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.

Patient Consent:

I have reviewed the above information that explains how Hands on Health - Family Chiropractor will use my personal information and the steps that the clinic is taking to protect my information. 

I agree that Lara Cawthra can collect, use and disclose personal information as set out above in the information about the clinic’s privacy policies. 

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Please note that this form must be signed prior to your first appointment. 

I hereby give my consent to the chiropractic treatment and procedures, including tests to be conducted in managing my condition(s).

I understand that in such chiropractic treatment, the chiropractor will use her bare hands.

Techniques are modified for the age and size of the patient.

Lara uses a tonal technique called NeuroImpulse Protocol (NIP), no cracking noise or crunching sounds are involved. NIP was originally developed to use on infants and babies and has since been adapted to be used on adults. No one anywhere in the world has reported being injured by this type of chiropractic adjustment (technique)

 
I have been informed that in chiropractic treatment or management of conditions, such are the known risks in adult patients using standard manual techniques:

• Soreness or symptoms or Increased pain by which such may occur temporarily after the first few treatments.
• Bruises or stiffness. With the use of devices, I understand that temporary soreness or bruising might occur. 
• Nausea or dizziness. In this event where these symptoms are felt, I shall inform my chiropractor right away.
• Fractures. It is my duty to notify my chiropractor in case I am aware that I have weak bones or have been diagnosed with any bone-weakening disease such as osteoporosis. The chiropractor may also halt or modify the procedure if he or she finds that such or similar condition is detected by her while under the latter's care.
• Spinal disc conditions like bulges or herniations.  In such a case, I will have to notify my chiropractor when such symptoms arise. 
• Stroke. I am informed that there has been no known direct association between chiropractic treatments and stroke. However, for safety purposes, I shall inform my chiropractor of any symptom of neck pains and headache which are known symptoms of a stroke.

I understand: 

- The clinic does not guarantee treatment results.

- That Lara Cawthra (Chiropractor) will explain to me the exact nature of any treatment provided and will answer any questions I may have. 

- I am free to withdraw my consent and to discontinue treatment at any time.

- I will be responsible for paying the financial charges for the services provided to me. 

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This section is in accordance GDPR

In order to contact patients about clinic changes, promotions, products, events, newsletters, workshops and programs, we require your consent below. You may choose to withdraw consent at any time and you will no longer receive emails from Lara Cawthra (Chiropractor), or Hands on Health - Family Chiropractor

Lara Cawthra (Chiropractor)

At Hands on Health - Family Chiropractor

23 Kingsley Ave, Camberley

Surrey, GU15 2NA

01276 501777

hello@camberleychiropractor.co.uk

www.camberleychiropractor.co.uk

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I want to provide you with support on your healing journey, and I endorse transparency and setting expectations up front so we are both on the same page with what I can provide outside of our visists together. This is our Communication Policy:

- Medical questions are not answered on Text Message or Social Media Platforms for legal reasons

- Email questions will be answered by my next business day.

- Urgent Questions: call the Office at 01276 501777 and leave a message with my reception. I will call you back as soon as possible, or if unavailable, reception will call you back with the answer I provided 

- Complex questions and new concerns: please book a 15 or 30 minute Telehealth follow-up visit so I can provide you with the  support you deserve

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Why do genetics matter? There is a large genetic role in risk of disease. Most times genetics do not guarantee a condition but they predispose one to certain conditions, and if we know your predispositions, we can actively work to prevent them from occurring.

Parent / Guardian 1

PLEASE ENSURE the email address you enter is accurate as this is the number one reason people are unable to access their exercises, or receive their appointment confirmation.

Parent / Guardian 2

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Health History

Nutrition / Diet

At what age did your child first:

Family History

Environment

Last Question!