Please fill-out the following in-take form


 

The more information you're willing to share, the better we can help you.  The fields marked with a star ' * ' are required.  All information shared is held in strict confidence and will only be read by the practitioner of the VHHC whom you have chosen work with.

 

Personal Information

Services (check what you would like to receive)

Your health concerns
Personal Health - past and present

Self-Care
How did you hear about us?
I agree and consent to the services & procedures offered by Seamus Robertson, Holistic Therapist. I understand that the services & procedures included under the umbrella of Holistic Therapy include techniques & procedures from the following modalities: Shiatsu Therapy, Tui Na Massage, Cranio-Sacral, Cupping, Qi-Gong, Reiki, Lymphatic Drainage Massage, Active Release, Orthopaedic Assessments, Rebalancing, Polarity Therapy, Hakomi, Hypnotherapy, Bodytalk, & Taoist Massage. I understand and agree to the nature of these services and the techniques involved in them. I understand that if I have any questions about this information & the above services & procedures it is my responsibility to educate myself on them. I understand that by agreeing to all terms listed herein, I am giving informed consent to the services and procedures above. I proclaim that all of the information above is complete and accurate and will inform Mr. Robertson of any changes or updates immediately. I understand that any information shared during any treatment, health consultation, and coaching sessions must be accurate, whole, and complete. I understand that all information shared by Mr. Robertson is not in any way shape or form to be misconstrued for medical advice. I understand that I must consult with my Naturopathic Doctor, TCMD, GP, or Family Doctor before proceeding with any personal regiments or procedures (ie. diets, cleanses, supplementation, herbs, etc.) pertaining to any of the information shared by Mr. Robertson. I understand that I am free to withdraw my consent at any time. I understand that Mr. Robertson himself is free to end any session at any time for any inappropriate behaviour, poor hygiene, lack of compatibility between us as people, and/or health concerns that may immediately affect the clinic as a whole (ie. contractible diseases) and that full payment is required regardless of treatment completion. I understand that possible side effects of any treatment by Mr. Robertson can be: bruising, swelling, temporary pain or discomfort, nausea, vomiting, sweating, skin eruptions, dizziness, bad body odour, headaches, fatigue, and blurred vision. I agree to pay full treatment value for any future missed appointments or when less than 48 hours notice is given before any appointment cancellation or schedule changes. I understand that my submission of this form by clicking the 'send' button below applies as agreement to all of the above and as governance and consent to this current and all future therapy sessions, treatments, and appointments. I hereby release Mr. Robertson from any and all liability that may occur in connection with my receiving and/or my lack of understanding of the above aforementioned services & procedures.


Send