Profile Form | BioHealthHarlow.com

Pre Appointment Personal Profile Form

First name

Last name

Address

Phone

Gender

Male

Female

Date of Birth

What do you do for a living?

Do you have any diagnosed health problems? (If yes, please list them)

Are you on any medication? (If yes, please list them here)

Are additional therapies are being unertaken for your current health problems? (If yes, please list them here)

If you have any injuries, please list them here

Please list any diseases or viruses that you are aware you have

Please list any conditions you are experiencing (Fatigue, Depression etc)

Please list any life stresses or emotional problems you are experiencing

Do you have any sleep issues?

What are you hoping to achieve with this treatment?

Cancellations

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance, may be charged in full to the client.

Late Arrivals

Please arrive on time for your appointment, as failure to do so may result in your appointment being cancelled. Please call us on 07740 360710 if you know you are running late and we can advise you on whether or not to attend your appointment

Correct Information

All the information I have given in this form is correct to the best of my knowledge.

I have sought and followed necessary medical advice and I understand that all the information given is to be kept confidential.

The following terms of use affect your legal rights and obligations. Therefore, you are required to read in full the following terms of use before signing this profile form.

Any products and services offered or information disseminated through the treatment and techniques received are for entertainment and informational purposes only. Bio Health Harlow and its trained practitioners are not licensed medical professionals and do not diagnose illness nor prescribe medication. The offerings of the treatments shall not be used in lieu of treatment from a licensed medical professional. The use or reliance of information and services provided does not constitute a patient-practitioner relationship. If you believe you suffer from a medical condition requiring diagnosis and treatment, we encourage you to contact a medical doctor or other licensed health care professional of your choice.

Any modalities or techniques offered through this treatment by Bio Health Harlow or any of the practitioners, such as Emotional Freedom Techniques (EFT), Tapping, guided visualization cellular release, emotional coping techniques and all other recommendations, techniques and materials are not to be construed as medical or psychological advice. This provision specifically applies to any services or contact between Bio Health Harlow or its practitioners and a user of the treatment through social media, webinars, in-person seminars and any other method by which said treatment or techniques may be provided.

You agree to hold harmless and indemnify Bio Health Harlow and it's practitioners and any agents thereof or thereto for any claim for injury or other loss sustained from the treatment received. This indemnification is intended to extend to any incidental or consequential damages arising from your treatment or any services or information provided by Bio Health Harlow or it's practitioners. You voluntarily accept any and all risks of treatment and techniques provided therein.

I AGREE TO THE ABOVE TERMS & CONDITIONS

Yes

Your Signature

Thanks for completing this form, we look forward to seeing your at your first appointment