Book a Consultation

Name *
Name
Mrs/Miss/Ms/Dr
Date of Birth
Date of Birth
Have you ever received the following? Check if the answer is yes.
Please select if any of the conditions below apply
Heart Conditions
Diabetes
Respiratory Condition
HIV/AIDS
Jaw Pain
Skin Condition
Lung Condition
Stroke
Deep Vein Thrombosis
Kidney Disorder
Sprain/Strain/Fracture
Arthritis
Digestive Problems
Epilepsy
High Blood Pressure
Neurological
Cancer
Osteoporosis
Dizziness/Fainting
Haemophilia
Possible Pregnancy
Low Blood Pressure
Spinal/Head Injury
Hepatitis
Headaches/Migraines
Contagious Illness
Wear a Pacemaker
Upcoming Surgeries
Do you use the following and if so, how often?
Do you participate in the following physical activities and if so, how often?
Please indicate whether you or any of your family members have, or have had the following:
Alcoholism
Allergies
Alzheimer’s disease
Arthritis
Asthma
Cancer (indicate type)
Mental illness
Diabetes
Drug abuse
Heart disease
High blood pressure
Kidney disease
Osteoporosis
Liver Disease
Suicide
Other familial disease
Food, Digestion and Sleeping habits
(sweet, salty, organic, wheat, dairy, meat, vegetables, fruit, pasta, fast foods etc.)
Work
Informed Consent
The CCHLive is delighted to have you as a client and look forward to providing you with the highest quality care. In order to optimise your relationship with us please take a minute to read our appointment policy. A 24-hour notice for cancelled or rescheduled appointments is necessary in order to avoid a cancellation fee which is the cost of the full treatment price. This allows us time to schedule another patient who would also benefit from treatment. This appointment policy allows us to develop a mutual consideration and respect for our time and yours. Please note that this form must be signed prior to your first appointment. As a patient you will receive information about your diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon. Privacy of your personal information is an important part of our clinic, and while providing you with quality care, we understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information. CCHLive is aware of the sensitive nature of the information that you have disclosed to us. Your therapist is trained in the appropriate use and protection of your information. I have read this statement and fully understand it.
Please enter two options.