Intake Form | Bea Sports Injury Clinics

0116 367 7597 contact@beasportsclinic.co.uk

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Thank you for booking with Bea Sports Clinic. If this is to be your first visit, please fill in the following Intake Form so we can best treat you. All information you submit is strictly private and confidential.

Patient Details

First Name *
Second Name *

Address

House Number/name and street address *

Town/City *

Postcode *

Date Of Birth *DD/MM/YYYY
Email
Phone

PATIENT MEDICAL HISTORY

Heart condition/angina *
YESNO
Details

Blood pressure problems *

YESNO

Details

Haemophilia/blood clotting disorders *

YESNO

Details

Blood borne virus, e.g. Hepatitis B/C or HIV *

YESNO

Details

Skin complaints, e.g. psoriasis, eczema *

YESNO

Details

Section

Diabetes *

YESNO

Details

Allergic response, e.g. anaesthetics, jewellery *

YESNO

Details

Section

Do you regularly take any blood-thinning medicines, e.g. aspirin? *

YESNO

Details

Do you take any regularly prescribed medication? *

YESNO

Details

Could you be pregnant? *

YESNO

Details

Details of any associated problems with treatment

Your Agreement

Declaration *
I declare that the information I have provided on medical history is correct to the best of my knowledge and hereby give consent for massage therapy or acupuncture to be carried out by the named practitioner. I confirm that I have been provided with written information on (i) the potential complications associated with the procedure and (ii) appropriate aftercare advice for acupuncture. I give consent to the practitioner to retain the details provided on this form for a period of 7 years from today.I Agree with the statement

Data Protection

How we use your data *
Under the Data Protection (1998) Act, and to conform with GDPR, we are required to advise our patients on our Data Protection Policy and how we handle your data. All information provided will be treated as confidential, and will not be given to any other person/organisation without the written consent of the patient concerned. As part of the Patient Record this clinic is required to retain information for the purpose of consultation for treatment and recording subsequent treatments. Use by third party medical practitioners will only be allowed with the specific permission of the patient in writing. Upon completion of the Patient Details Form, Data Protection and Consent form, all paper files and information may be electronically scanned and stored on a computer file, or alternatively retained as paper records, for as long as the patient remains a patient of the clinic, and thereafter for a period of 7 years . Information held both manually and electronically in files will be accessible only by staff of the clinic directly involved in the data entry and processing of patient records. By ticking this box, you acknowledge that you have read the Data Protection Policy and hereby give consent to the practitioner to maintain records for the purposes outlined within this Policy.I agree to your data policy
I declare that I am 18 years old or older

Thank you

Please enter any two digits *Example: 12
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