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Consent Form

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Cherry Blossom Kinesiology

Consent Form

Client Details

First Name:
First Name
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Date of birth:
Select a date
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E-mail address:
Your E-mail Address
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Last Name:
Last Name
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Contact Number:
Best number to call on
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Emergency Contact

First Name:
First Name
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Emergency Contact Phone:
Emergency Contact Phone Number
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Last Name:
Last Name
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Relationship to you:
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  • Spouse/Partner
  • Parent
  • Daughter
  • Son
  • Friend
  • Other Family Member
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Medical History

Are you taking any medication or supplements?
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  • Yes
  • No
- select
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Please list here:
Please list all supplements you are currently taking
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Do you have any allergies?
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  • Yes
  • No
- select
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Please list here:
Please list any/all allergies
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Kinesiology

Have you previously received kinesiology?
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  • Yes
  • No
- select
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What are your thoughts on your previous experience(s) of kinesiology?
Please provide details
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Please list any fears, phobias or compulsive tendencies:
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How would you like kinesiology to help you?
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Do you have any other notes you wish to make?
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Consent

Please read and sign below
I hereby authorise the kinesiologist named below to use treatment techniques on me for the purposes outlined in this form, and for future purposes that I may request.

I understand that kinesiology treatment is not a medical procedure and that no medical benefits are being offered to me.

I understand that the success of the treatment depends on my ability to relax and my desire to create change in myself.

I understand that, because the results of the sessions depend on my own serious participation, the kinesiologist cannot offer any guarantee of the success of my treatment. I am aware, however, that they will do everything reasonable in their ability to ensure my success.
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Kinesiologist Name
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  • Rachael
- select
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Data Protection & GDPR

Data Protection & Privacy
We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

The only data we will store are name, email address and phone number. No medical information or answers to these sorts of questions will be gathered or stored on this website in a database.
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I consent to my submitted data being stored in accordance with the Privacy Policy
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