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Patient Consent Details
Please enter details as accurately as possible.
Client Consent Form (#15)
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First Name
Last Name
Date Of Birth
Email Address
Age
Sex assigned at birth
- Select -
Male
Female
Height (Ft/cm)
Weight (Kg/lbs)
Phone no.
Next Of Kin
Next Of Kin (Phone Number)
Next Of Kin (Address)
Retired?
Yes
No
Occupation
Disability ?
Yes
No
If you selected 'Yes' to disability, what is the disability?
Who is your primary care doctor?
Address of primary care doctor?
Phone Number of primary care doctor:
Allergies
Yes
No
If so, please specify
Are you taking any Medications? If so, Please specify
Allergic to any medications? If so, Please specify
Do you smoke?
Yes
No
If you recently quit smoking, when did you quit?
Do you drink alcohol?
Health condition
Alzheimer's
Back Pain
Cardiovascular Disease
Chronic Pain
Diabetes Mellitus
Digestive Disorders (e.g: Irritable Bowel Syndrome)
Depression
Respiratory disorders (e.g: Bronchitis, Asthma)
Kidney Disease
Osteoporosis
Other
Not Applicable
If other, Please specify
Anything you need to tell the doctor before your assessment?
Confidentiality Agreement
Check this box to agree to this confidentiality agreement: All information disclosed within sessions and the written records about those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
Consent Agreement
Check this box to agree: Signing this form indicates that you are voluntarily and knowingly undertaking our BIPI Assessment -a biophysical method of General Health Assessment designed to complement conventional medicine. Areas of Treatment Concern is non-invasive and painless; it neither requires nor involves any medication. I understand that the practitioner does not claim in any way, fashion, form, or manner to cure or diagnose any medical condition using the same techniques that a Doctor or Physician would traditionally perform. The Practitioner Opinion is that of a Holistic, Complementary and Alternative Practitioner and their Professional Opinions, Advice, Examinations and Recommendations do NOT constitute the Medical Advice of a Doctor or Physician. At no time will the Practitioner state or imply that a client should discontinue taking any medication prescribed by his or her physician. At no time will there be any implied or stated indication or suggestion to any client to discontinue their present care under the direction of a physician. This assessment is not intended, implied, or stated as suitable to replace or interfere with any conventional medical test or diagnostic procedure prescribed by a Licensed Medical Practitioner. At no time do we guarantee to resolve a current health concern. However, that having been said, it has been found that Client-Compliance to the Complete Recommended Therapy usually results in greater and more consistent health improvements. Having fully read and understood the above information regarding the elements of my rights and my responsibilities in this matter: I hereby give my Informed Consent to my being Health Assessed by the use of Wellness Therapy Equipment and Procedures. I understand that if I have been untruthful with my details or have failed to provide enough relevant information then the outcome of any therapy could be adversely affected and my health and well-being may be put at risk. By signing this form, I agree that the questionnaire results for my meeting with one of your consultants will be stored. I can request its deletion at any time.
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