QEC Medical Indemnity Form

QEC Medical Indemnity Form

by Dr Melanie Salmon
Name

First NameLast Name
Birth Date

DayMonthYear
Gender
Country of birth
Country of residence
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
name@example.com
Telephone
Please include country dialling code
Occupation
Are you (or have you been) married?
How many children do you have - if any?
Name of regular GP or specialist
Medications you are currently on
How did you hear about QEC?

Other
If you have selected "other", please share more:
Please share the main reason you are coming to QEC
Do you have any current medical problems?
Have you had any surgery? Please provide details:
Have you had any vaccinations in the last 5 years? Please provide details:
Please give any details of any mental health issues you have had / if you have been treated by a psychiatrist / if you have been in hospital for a mental health issue:
Do you have any other health concerns not covered above? Please provide details:

Past History
PRE BIRTH: Was your mum stressed during her pregnancy with you?
BIRTH TRAUMA: Were you born early/late? Required forceps/surgery? Did you spend time in an incubator?
FIRST 3 YEARS: Who was the main carer? Where you breast or bottle fed? Was there stress in the family during these years?
AGE 3-12 : Are you aware of any stresses at home, primary school or in your family circumstances during these childhood years?
AGE 13 -18 : Are you aware of any stresses, traumas or challenges during your teenage years?
YOUNG ADULTHOOD: Are you aware of any challenges, stresses or traumas during your after school years?
Please add anything else not mentioned above:

INDEMNITY
CONFIDENTIALITY CLAUSE

Everything discussed within the con nes of our work together shall remain confidential and shall not be divulged to any third party by your QEC Practitioner. Non identifying case material may be discussed during supervision.

EXEMPTION TO CONFIDENTIALITY CLAUSE

If I believe from our work together that your life is in danger, or the life of someone else is in danger, I will inform you that I need to break confidentiality in order to get help.
CANCELLATION CLAUSE

I agree to give a minimum of 24 hours notice when cancellation my QEC session. Failure to do so will result in full payment of the missed session.
QEC PRACTITIONER CODE OF CONDUCT

I understand that the QEC Practitioner o ers services in alignment with the Code of Conduct for QEC Practitioners, a copy of which is available to me upon request.
INDEMNITY

I undertake this QEC treatment of my own accord and indemnify the QEC Practitioner from any harm, loss or damage of any nature, whether bodily harm, trauma or any other damages to my person or property result from the treatment whether directly or indirectly.
EMERGENCY CONTACT

Please share an emergency contact below.
Emergency contact full name

First NameLast Name
Emergency contact number
Please include the country dialling code
Relationship
(e.g. partner, parent, friend, cousin)
I have read all of the above and confirm it to be true:
Full name (client)
Typing your name above in the signature box counts as acceptance of all terms stated in this document and indemnifies Quantum Energy Coaching (QEC Ltd), its employees, suppliers and your practitioner from any future claim whatsoever.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate

GDPR PRIVACY POLICY
This privacy policy will explain how your QEC Practitioner uses the personal data collected from you in this form.
TOPICS

•What data do we collect?

• How will we use your data?

• How do we store your data?

•What are your data protection rights?

• How to contact us
WHAT WE DO WITH YOUR DATA

Your practitioner collects the following data:

• Personal identi cation information (Name, email address, phone number, etc.)

• Your medical history - as it relates to your QEC sessions.
HOW WE WILL USE YOUR DATA

Your QEC practitioner collects your data so that they can gain a basic understanding of your medical history, to provide

insight and understanding that might be bene cial when beginning your QEC therapy. Your data will always be treated

with the strictest con dentiality and will never be shared with anyone else.
HOW DO WE STORE YOUR DATA?

Your medical indemnity form will be filed and stored by your practitioner for a period of up to 10 years. Once this time period has expired, your data will be deleted.
WHAT ARE YOUR DATA PROTECTION RIGHTS?

Every client is entitled to the following:

The right to access - You have the right to request a copy of your personal data as collected in this form.

The right to rectification - You have the right to request that your QEC practitioner corrects any information you believe is inaccurate. You also have the right to request that your practitioner completes information that you believe is incomplete.
HOW TO CONTACT US

If you have any questions about this medical indemnity and data privacy policy, the data we hold on you, or you would like to exercise one of your data protection rights, please do not hesitate to contact your QEC practitioner. If you would like to speak directly to the QEC data protection officer, please contact Anima at connect@qecliving.com
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QEC Medical Indemnity Form

Past History

INDEMNITY

I have read all of the above and confirm it to be true:

GDPR PRIVACY POLICY