Medical Form

Please take a few moments to fill in our form and provide essential information as indicated below. Accurate information is necessary for your health assessment. A false declaration may result in rejection of treatment.

All the health records and photographs of patients are kept highly confidential to ensure complete privacy and anonymity of the patient.

Terms and Conditions:

  1. Your medical history is used for primary screening/evaluation before seeing our practitioner
  2. If the practitioner advises/recommends the patient to see a doctor for additional consultation before treatment and the patient refuses to do so, the practitioner has the right to cancel the treatment/booking.
  3. I hereby request and consent to the performance of assessments, various modes of physical therapy, laser therapy, and other procedures, on me by the practitioners listed at this clinic and or anyone working at this clinic authorized by the practitioners. I have had the opportunity to discuss the nature and purpose of assessments, various modes of physical therapy, laser therapy and other procedures. I understand that results are not guaranteed.

Contact Information

In Case of Emergency

Additional Information

Exclusion Criteria for Spinal Decompression and Deep Tissue Laser Therapy
Please tick any that apply

 

Acknowledgement

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Active Again of any change in my medical status.