Realign and Revive consult

Thank you for booking with Realign and Revive.

Full terms and conditions (including how and why your information is stored) is available from the website at www.realignandrevive.com/faqs

Please do not bring a child to your appointment with you as they cannot be left unattended in the waiting area and cause a distraction in the treatment room. If you bring your child then the appointment will not go ahead but you will still be charged.

Once you have completed and submitted the form below Julie from Realign and Revive will printit to check the information at your appointment. This form will then be stored in a locked filing cabinet.
Realign and Revive*

I consent that my personal data can be collected by Realign and Revive in order to carry out my treatment.I consent that information may be shared with my G.P. if necessary.I consent to be contacted regarding news and events from Realign and Revive.I consent for the type of treatment I receive to be disclosed for the purposes of someone purchasing a voucher for me as a gift.
As full payment has been made at time of booking the Booking and Cancellations policy must be updated. This is to ensure both clients and the business are served in the best possible way. If I can fill a rescheduled or late cancellation appointment slot then the fee will be waived.

If you cancel with 48 hours or more notice from your appointment time then you will be offered a refund or to reschedule your appointment. (If using a voucher then you will be offered to reschedule only.)

48+ hours notice = no cancellation fee.

If you cancel with less than 48 hours but more than 24 hours from your appointment time then you will have lost 50% of your appointment fee, the remaining 50% can be refunded or applied to your next appointment. ( If using a voucher you will have lost your voucher and cannot be used for a later date).

24-48 hours notice= 50% cancellation fee

If you cancel with less than 24 hours notice or fail to attend your appointment then full payment is required and no refund will be given. (Vouchers will be lost and cannot be used for another date.)
I have read and agree to the Booking and Cancellations policy as outlined above for all appointments at Realign and Revive.
Signature*

Clear
Date*

DayMonthYear
Date
Client full name*
Date of Birth*

DayMonthYear
Date
Address *
Postcode*
Phone number*

Area CodePhone Number
Email*
example@example.com
Occupation
Specific reason for treatment
GP Practice details
Practice name*
Address
Do you prefer chatting or quiet? Please select.*

Happy to chat.Prefer as little chat as possible.
Health Conditions. Please mark all that apply.

This is to ensure your treatment is as safe as possible and does not cause any exacerbations of existing conditions.
Mental fatigueSchizophreniaAsthma COPDThrombosis/ PhlebitisHeart ConditionHigh blood pressureLow blood pressureEczema/ dermatitis/ psoriasisIndigestion/ acid reflux/ IBSConstipationDiarrhoeaKidney diseaseOsteoporosisRecent broken bonesPain/ InflammationRheumatism/ ArthritisJoint problemsMuscle problemsScoliosisLordosisKyphosisSpondylosisPregnancyMenopausePMTDiabetesOver active thyroidUnder active thyroidEpilepsyHeadache/ Migraine
Any other health concerns/ including surgeries and medical implants. If none please write none.*
Any known allergies. Please list. If no known allergies please write none.*
Any medications/ supplements. Please list all medications including names of each medication. If on no medications please write none. *
I hereby consent to Julie from Realign and Revive to treat me with whatever skills she sees fit within her scope of practice in today's treatment and any further subsequent sessions deemed necessary.

I have completed this form as fully and accurately as I can. I believe the details to be correct and consent to having treatment with the above mentioned therapist. I release the practitioner from any negligent misrepresentation that may be contained in this form.

I agree with the terms and conditions of treatment, the booking and cancellations policy which is found on the FAQs section of the website and booking system.

I also fully understand that I can stop any such treatments at any time, simply by clearly saying the word "STOP" should I feel so inclined for any reason.
Client Signature*

Clear
Date

DayMonthYear
Date
Should be Empty:

GP Practice details