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Rehabilitation - Application Form

Rehabilitation - Application Form

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    Veuillez sélectionner
    • Veuillez sélectionner
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Autre
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    Common sense is your best guide when you answer this health questionnaire, depending on your answers and condition you maybe asked to consult your GP for additional medical clearance or info prior to beginning your recovery plan.

    Please read the questions carefully and answer each one honestly: check YES or NO. 

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    These are a list of contraindications, they are important to ensure you don’t have prior to massage treatment as it may cause negative effects to your health.
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    Zero equals no pain and 10 equals excruciating pain
    • Scale 1 - no pain
    • Scale 2
    • Scale 3
    • Scale 4
    • Scale 5
    • Scale 6
    • Scale 7
    • Scale 8
    • Scale 9
    • Scale 10 - excruciating pain
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    Zero equals no pain and 10 equals excruciating pain
    • Scale 1 - no pain
    • Scale 2
    • Scale 3
    • Scale 4
    • Scale 5
    • Scale 6
    • Scale 7
    • Scale 8
    • Scale 9
    • Scale 10 - excruciating pain
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    • Constant
    • Off/On
    • At Rest
    • With Activity
    • Lying down
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    • Morning
    • Afternoon
    • Evening
    • During Sleep
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    Please include the benefits/Effectiveness you found from these treatments
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    • Back
    • Left side
    • Right side
    • Stomach
    • Stomach facing left
    • Stomach facing right
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    Please tick ☑️ Any symptoms that apply to you and indicate right or left when applicable
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    Please tick ☑️ Any symptoms that apply to you and indicate right or left when applicable
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    Please tick ☑️ Any symptoms that apply to you and indicate right or left when applicable
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    Please tick ☑️ Any symptoms that apply to you and indicate right or left when applicable
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    Please tick ☑️ Any symptoms that apply to you and indicate right or left when applicable
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    Please tick ☑️ Any symptoms that apply to you and indicate right or left when applicable
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    Please tick ☑️ Any symptoms that apply to you and indicate right or left when applicable
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    Please tick ☑️ Any symptoms that apply to you and indicate right or left when applicable
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    Next you are required to provide a signtures, by signing you are declaring all the information is correct and the facts provided are honest and true of yourself, you are also agreeing to all assumptions of risks and agree with all terms and conditions including Health & Safety Policy.

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    by signing below you are declaring all the relevant information provided is a true and honest fact of yourself.
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    I am aware of the risks in observing or participating in the activities/treatments offered and sponsored by MB Performance Training & Rehab/ MB Health & Fitness Studio.

    I understand that all sports, fitness or rehabilitation exercises that I will execute and participate in are entirely at my own risk and perils.

    I realise that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to property/equipment, or damage arising out of my death.

    It is understood that MB Perfomance Training & Rehab/ MB Health & Fitness Studio is NOT responsible for any damage that would be resulting a fault of my own. 

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    by signing below you are declaring agreement to liability weaver and agree assumptions of risk are solely my own.
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    Treatment Policy

    Client/Patient information is kept private and confidential. Written consent/authorisation is required to release information.

    Please ensure the following:

    • turn mobile phone off.
    • please reschedule your session if you are more than 15 mins late (cancellation policy applies)
    • please wear appropriate clothing to enable practitioner to access relevant area for treatment, you will be draped however at no time will you genitalia or breast tissue be exposed
    • each treatment you will receive a review of your previous treatment and issues to ensure appropriate treatment plan is applied
    • at any point you or practitioner can end session at any time for any reason
    • inappropriate behaviour will not be tolerated and my be prosecuted to the full extent of law

    Client Agreement:

    Practitioner/therapist dont diagnose illness, disease or physical/mental disorders, nor do they prescribe medical treatment or pharmaceuticals.

    Client understands it is there choice to receive treatments in the form of massage, cupping, dry needling/acupuncture, spinal manipulation, taping etc to ensure the necessary treatment plan is implemented to address and prevent pain, myofascial issues, injuries and dysfunction.

    Client understands that at any time pain or discomfort may be felt during the session, communication with the practitioner is essential to ensure the right amount of pressure is applied.

    Client understands any changes in medical conditions must be updated immediately with practitioner, failure to rise any issues will result in potential threat to health and liability will be held in clients responsibility.

     

    Payment Policy:

    Consultation charge is £65.00 for up to 90 minutes to enable subjective and objective assessments, a treatment is also included.

    After consultation treatments are charged £50.00 per treatment

    After 3 progressive/adaptability treatments clients/patients are entitled to monthly maintenance discount monthly payment system at discounted rate via direct debit, the benefits of this are:

    • Guaranteed appointment
    • Emergency treatment service
    • Discount off additional treatments
    • Rehabilitation/Programming app access etc.

    PLEASE understand regular appointment times are usually for up to 60mins, during this time a mini review will be completed, allowed changing times and enough time to review the treatment and time arrange next appointment, this doesn't mean the treatment is for 60mins.

    Cancellation Policy:
    All cancellations must be received at least 24h before your session start time in order to avoid being charged. 
    Clients who do not cancel with 24h notice will be charged a regular price session for the cancellation.

    MB Perfomance Training understands that emergencies can happen. Every client is entitled to ONE free short-notice cancellation. You will not be charged for your first cancellation that is within less than 24h notice however subsequent short notice cancellations will be charged for at the regular priced session.

    The first time - free short-notice cancellation only applies if notice prior to the session start time.

    No show are not eligible for the free cancellation.

    In regards to membership cancellations or changes you must give 30 days’ notice and this must be completed in writing by emailing info@mbperformancetraining.co.uk

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    by signing here you agree to adhere to the terms and conditions.
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