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health questionnaire

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Personal Details

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I have read, understood to my full satisfaction, and completed this health questionnaire.

I acknowledge that a registered clinician will perform my assessments and treatments.  I understand that with certain conditions a degree of undress may be required and that this will be explained to me at the time by the therapist, as will treatment techniques and electrical modalities used.  Following an examination and assessment, an explanation of the clinician’s opinion and proposed treatment will be given to me.  At any time, I am entitled to request a chaperone to be present during my assessment or treatment.  

I acknowledge that all treatments/ sessions, including those to be part of an insurance claim, must be paid for in advance (with the exception of some insurance schemes). I understand and agree that I am responsible for any amount not covered by my insurance company. Programs are required to be pre-paid in full and are non-refundable and non-transferrable.  

LEAR cannot be held responsible for any damage or loss to personal property whilst on company premises.  I hereby give my permission for my data to be shared with my insurer/other medical practitioners as deemed appropriate.  

I have read, fully understood and completed this questionnaire.  The answers that I have given are accurate to the best of my knowledge. I also state that I wish to participate in activities that may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me within my partnership with LEAR.  

CANCELLATION POLICY: SESSION FEES WILL BE CHARGED IN FULL IF AN APPOINTMENT IS MISSED OR CANCELLED WITHOUT AT LEAST 24 HOURS NOTICE.

Thank you! Your submission has been received and a member of the team will contact you as soon as your registration has been reviewed!
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