Crowthorne Body Health Patient Consent to Treatment

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Relevant health information and consent for treatment

Email *

Name *

Mobile no *

To my knowledge I am not currently experiencing any Covid19 symptoms. *

I have had a Covid19 vaccine

I have previously contracted Covid19

Neither of the above

Required

If you have been received any Covid19 vaccinations or you have tested positve previously, when did you have your last vaccine dose or when did you test positive for Covid19?

YYYY

If you have tested Positive for Covid19 in the last 5 days, please follow Government guidelines of self isolating. If you are self isolating, please contact your therapist to reschedule your appointment.

My medical conditions have not changed since my last treatment with the therapist. *

True

False

Required

I confirm that the above information is accurate to the best of my knowledge and that I am happy to undergo treatment. I know no reason why I should not receive treatment. I understand that treatments undertaken by me are at my own risk and that the therapist may not be able to cure my condition. I understand and agree to receive the treatment explained to me by the the therapist. I will keep the therapist up to date with any changes to my medical, mental and physical health.

Signature (type your name if you dont have an electronic signature) *

Date *

YYYY

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