House of Shen Client Intake Form

House Of Shen Intake Form

     

    CONTACT DETAILS:

     

    PERSONAL DETAILS:

     

    HEALTH CONCERNS:

    • MEDICATION:

    • SUPPLEMENTS:

    • INJURIES OR SURGERY:

     

    DIGESTION:

     

    SLEEP:

     

    EXERCISE:

     

    OVERALL:

     

    PRIMITIVE:

    • Menstrual Cycle:

     

    PAIN / ACHES:

      Experiencing in the following regions? And based on a scale of 1-10 and how often

     

    PECULIAR/ DIFFERENT/ STRANGE/ WEIRD:

    • I authorise my child and or myself to attend House of Shen and undertake all of the activities and/or to perform in the above program. In case of a emergency, I authorise House Of Shen/ staff, where it is practical to communicate with me , to arrange for my child and or myself to receive such medical treatment or surgical treatments as may be deemed necessary. I also undertake to pay or reimburse costs which may be incurred for medical attention, ambulance transport and drugs while my child and or myself is attending the centre/ program. I understand that although House of Shen and its services providers attempt to minimise risk of personal injury within practical boundaries, accidents do happen and all physical activities carry the risk of personal injury. I acknowledge that there is a inherent risk of personal injury in physical activities that will be undertaken at the centre as part of the program and I accept that risk. I have complied this information to the best of my knowledge. I understand that Holistic Kinesiology is a health aid in no way to take the place of doctors care when its indicated. Information exchanged during any session is educational in nature and is intended to assist me to become more familiar and conscious of my own health and is to be at my own decisions.

      By checking the box below you agree to the above authorisation. All sessions do require a full 24hrs cancellation period otherwise full payment will be charged. Thank you, with LOVE - House Of Shen
     

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