Name
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First Name
Last Name
Date of Birth
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MM
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Mobile Number
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Email
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Where did you hear about us?
Current health, I would like help for?
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Previous injuries
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Have you had any previous injuries, spinal surgery or motor vehicle accidents
If yes, please give details:
Do you smoke?
Yes
No
Do you drink more than 4 caffeine drinks per day?
Yes
No
How often do you exercise?
How many hours of sleep do you get on average per night?
What do you do to relax?
Are you on a restricted diet / any medical change diet?
Yes
No
If yes, please give details
Health History
*
Please tick if yes for each of the following:
Are you pregnant?
Marketing
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I am happy to receive health information, free information guides and practice updates from Hope Spinal Wellness. We never pass your details onto any advertisers. Hope Spinal Wellness Privacy Policy Note is available on our website or by request
Hope Spinal Wellness Massage Therapy Policies
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Fees for massage therapy sessions in 2023 are £38 for 30 minutes, £48 for 45 minutes and £58 for 60 minutes.
Massage payment can be made by cash or card on the day of your appointment or in advance by bank transfer, we do not keep accounts.
We appreciate 24 hours notification to change an appointment. Please note cancellation of less than 24 hours notification may be charged at full fee. If you fail to attend a massage appointment without notifying us ALL future appointments will need to be paid for in advance.
Should you fail to attend your scheduled massage without notification or arrive significantly the massage fee will still be incurred. Therefore we highly recommend you arrive on time or a few minutes early for your appointment.
Your appointment is booked for 30 to 60 minutes depending on your scheduled massage, within this time period we allow 5 minutes for changing clothes either side of the appointment.
At Hope Spinal Wellness we have limited car parking spaces available. We cannot guarantee space will be available onsite at your appointment time so please allow enough time to find alternate parking if necessary. Please park courteously so others can also use the car park.
*We have your current contact details and mobile number at all times to contact you and please inform Hope Spinal Wellness of any changes to any of your contact details.
* If you have regular massages please let us know if you are going away on holiday or need to change your regular schedule.
*We have an amazing series of Health Workshops on selected Wednesday evenings at 6:30pm on how to eat, move, and think better to create optimal health please see front desk to book.
*8 Weeks to Wellness and functional fitness training is available please ask your therapist or see front desk.
*Please make us aware of any changes to medication or any recent injuries/accidents.
*Please keep your underwear (pants) on for your massage.
*Please leave any muddy, wet or messy shoes downstairs on the mat provided before going up to massage or gym area.
*If you would like to read Hope Spinal Wellness Practice Privacy Policies then visit our website or request in office.
*Please join us on Facebook @ Hope Spinal Wellness Chiropractors Canterbury OR in our exclusive group Hope Space Virtual Practice, to stay in touch with all our practice, massage and promotional activities.
HOPE SPINAL WELLNESS is owned and operated by Veronica and Scott Hope. Please, if at any time you have any serious concerns or complaints about our office or employees, could you direct these matters immediately to Scott Hope on
01227 477004 or admin@hopespinalwellness.co.uk.
All healing takes time. If you do not feel satisfied with your body’s responses please make an appointment to discuss this with your practitioner. We want you to get the most from your massage therapy. Please note your massage therapist is NOT a registered Chiropractor. If you wish to see a Chiropractor, please speak to front desk to arrange an appointment.
I have read and understand the above policies, and I hereby give consent to receive massage therapy:
COVID Consent
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I understand the current government guidelines regarding social distancing and non-essential contact have been removed.
I confirm that to the best of my knowledge, I do not have Covid nor am I displaying any such symptoms for my appointment.
I will notify Hope Spinal Wellness immediately if this changes.
Date
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