Appointment Request/Client Intake

NEW CLIENT APPOINTMENT REQUEST - INITIAL CONSULTATION

Please complete and submit this form. We will revert very soon with a suitable appointment for you.
Please read the following to ensure that we are a good fit for each other.

We are selective in who we work with and we only work with people who are willing to commit to a treatment plan and do the work required. We do not provide "quick fix" treatments or work with clients who will not adhere to a treatment/reahb plan.

WHO WE WORK WITH
1. Athletes or active people who are struggling with pain, injury, re-occurring injury or recovering from surgery.
2. Those who are 100% committed and place value on their overall health and wellbeing.
3. Those who want to get to the root cause of their pain/injury and who want to achieve long terms results.
4. Those who will adhere to a treatment plan and carry out their rehab as prescribed with consistency.
5. Those who are of reasonable to good health and movement abilities, who want to work on their body to achieve their desired results.
6. Those who have been failed by other Therapists or Methods.
7. Those who are open minded and willing to learn.
If this sounds like you - please complete the remainder of the form below

WHO WE DON'T WORK WITH
1. Anyone just looking for a massage or a quick fix.
2. Anyone looking for last minute or emergency appointments.
3. Anyone prone to making excuses or cancelling or rescheduling appointments on a regular basis.
4. Anyone who consistently turns up late for appointments.
5. Anyone who is not willing to complete their rehab programme.
6. Anyone of poor health, fitness or movement levels.
If this sounds like you, we are not a good fit for your needs and it would be best for you to seek a more suitable clinic for your needs.

CANCELLATION POLICY & APPOINTMENT TIMES

We have a strict 24 hour cancellation or reschedule policy in place. Failure to provide us with a minimum of 24 hours notice may incur a cancellation fee of €35.00. No shows will incur the full charge of €70.00. We reserve the right to refuse appointments to anyone who peatedly cancels or reschedules without sufficient notice.

We endeavour to stick to allocated appointment times. Lateness to appointments will be deducted from your scheduled appointment slot. We will allow a buffer of 10 minutes but anything over this, we reserve the right to turn you away.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
E-Mail address*
example@example.com
Phone Number
Please enter a valid phone number.
GP Name and Location*
Occupation*
What times suit best for appointment*

Mornings 10 am- 12 noonAfternoons 1 pm - 4 pmEvenings only - after 5pmAny time suitsMy rota changesOther
Please specify further if you have specific time requests *
GENERAL FITNESS/HEALTH/WELLBEING
What are your current activity levels?*
Do you smoke, drink alcohol regularly or take drugs in any form? (please select one or more if relevant)*

I smoke/vapeI take drugs regularly or recreationallyNone of the aboveYes I drink alcohol more than once per week
Which sounds most like you?

I just want to be pain free/I am looking for a quick fix.I am looking for long term changes/ I want to improve my health/fitness/wellbeing and I am willing to work at it.
What is your Nutrition & Hydration like?

GoodFairPoor
Do you take any time for yourself to unwind or for your interests?

Yes, most daysNo, I am too busyI relax by scrolling on my phone or watching tvOther
Medical History
Have you ever or do you suffer from (Please check all that apply)

AsthmaArthritisCancerDiabetesEmotional DisorderEpilepsy SeizuresHeart AttackHigh Blood PressureSleep ApneaNeurological DisordersBleeding DisordersLung DiseaseObesityOsteoarthritis
Please list current medications and any drug allergies
Injury History
Have you had previous injuries/surgeries to any of the following - If yes, please provide information in the box below*

Head/Neck/SpineHand/Elbow/Shoulder/ArmToes/Ankle/Knee/LegPelvis/Hip/RibsI have never had a single injury in my entire life
Please list all injuries in chronological order - try and provide as much information as possible, no matter how irrelevant you feel it may be or how long ago it happened. If you never had any previous injuries/surgeries, please state same below.*
What is the current problem and how long has it been going on for?
How is this affecting you day to day or what is it preventing you from being able to do?
What is your dream outcome and what are you hoping to achieve from today's session? (Just to be pain free is not an answer)*
Have you tried any other type of treatments/therapies*

No payment will be taken upon submission - this is for card verification purposes only to secure your appointment booking*

Card VerificationCard details will be held securely via Stripe and no other parties will have access to same.

€ Free Quantity

Total

€0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

CONSENT AND DATA PROTECTION

All information provided will be dealt with in the strictest of confidence and will not be shared with any other parties. The only person with access to this information is your therapist.

TREATMENT PLAN AND REHAB

Our aim is to help you to return to pain free movement and to the things you love doing.

This involves creating a treatment and rehab plan based around your needs and required outcome. It is important that you understand this and are committed to achieving your end results by following the plan we agree upon.
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NEW CLIENT APPOINTMENT REQUEST - INITIAL CONSULTATION

GENERAL FITNESS/HEALTH/WELLBEING

Medical History

Injury History