Please detail below any medical, allergy, or health conditions you may have, along with any prescribed or non-prescribed medicine or supplements you are currently taking.
I agree I have not withheld any information about any medical conditions and that to the best of my knowledge I am fit to receive hands on physical healing including massage, manipulation of joints, and other forms of body work. I will inform my practitioner when and if there are any changes to my health or if I feel that there is any doubt as to whether I should receive treatment. I am also aware certain treatments during pregnancy may be harmful to both the parent the baby and take full responsibility to inform the therapist prior to the session if there may be a chance of pregnancy.
I understand that I may be treated by a fully insured student who is currently studying and has not completed or passed their course at this time and I am happy to receive the treatment.
I understand the nature of physical contact in the therapy sessions and I understand that I have the right to immediately withdraw from any session which makes me uncomfortable or I am not entirely happy with.
I grant permission in case of injury to have a doctor, nurse, or other emergency medical personnel provide me with medical assistance or treatment. I give the therapists and staff and responsible adults the power to authorise medical treatment by granting my authorisation. I assume responsibilities for all decisions made, provided they are reasonable decisions under the circumstances based on the knowledge and understanding of the person making the decisions, and I trust their judgment and offer the benefit of the doubt to them in any claim or legal proceeding.
I understand that the therapists and staff may have some skills in first aid, CPR, and at their discretion, I authorise them to use those skills and techniques to assist in any circumstance in which they judge their skills would be necessary or helpful. I will inform my therapist in writing if I wish to be DNR (do not resuscitate)
Whilst many people have reported physical, emotional, mental, psychological, and spiritual benefits from attending healing and/or therapy sessions, I acknowledge that no claims, promises, or guarantees are being made as to the results and effectiveness of any treatment and therefore accept full responsibility for the outcome of said treatment.
I understand that PW Therapy cannot be held responsible or liable for any adverse side effects or reactions that may occur as a result of receiving treatments. I understand that the information and treatments provided are not intended to be a replacement for medical treatment and patients are advised to always consult with a qualified GP or consultant before adopting any of the suggestions or taking part in the therapy sessions provided.
I understand I have given full consent to be treated and my GP, or other health professional has not advised against any forms of therapy.
I hereby understand that by its very nature Chinese medicine, (including, but not exclusive to, acupuncture, acupressure, massage, herbs, aromatherapy, direct and indirect moxibustion, cupping, gua sha and electrical stimulation), may cause minor discomfort and may irritate the skin or leave a mark, puncture the skin, bruise, or burn.
To ensure there is no misunderstanding between the therapist and you the patient, the therapist will give you a full explanation of all the procedures that will be undertaken in your treatment session. Some examination and treatment procedures used by therapists may involve intimate areas of the body. In such cases the therapist will gain verbal consent from you, in conjunction with this written consent. The therapist is also aware that the definition of intimate areas can vary within different cultures and religions, and that you, the patient, will be allowed sufficient time to decide to give your consent without feeling under pressure to agree, what is often termed “coersive consent”.
Both the therapist and client have the right to request a chaperone to be present at the treatment. A minimum of 24 hours must be given by ether party to agree on a suitable chaperone. If the therapy is to be given on a person 16 years or younger, or to anyone deemed to have learning difficulties, special educational needs, or other similar difficulties, there must be a chaperone present. This responsible adult with assume the part of the patient in agreeing to the above terms and conditions. The therapist will also gain verbal consent from the patient to ensure they understand and are happy to receive treatment.
The therapists, and staff at PW Therapy have the right to refuse treatment and to stop the session at any time and all monies paid for the session to be paid in full within 7 working days.
Please note PW Therapy has a 24-hour cancelation policy. This is for the benefit of both the patient and the therapist. PW Therapy reserves the right to request payment in part or full for any cancelations made within this time frame. Pre-paid sessions are also subject to the same 24-hour notice period.
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We would also like to obtain your consent for being contacted via email to remind you of bookings or orders
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