Treatment Consent Form

Required Forms

Please fill in our consent form below, or download the PDF or Word Document to bring in with you.

Treatment Consent Form Treatment Consent Form 

INFORMATION AND TREATMENT CONSENT

You will be treated with care and respect at all times and all information disclosed during consultations/treatments will remain confidential.

If you are receiving treatment from your GP, hospital or other professional practitioner for any medical condition it is recommended that, should you consider it appropriate, you inform all parties concerned that you are receiving Rolfing treatment.

Rolfing does not take the place of conventional medical treatment and in Rolfing treatment there will be no diagnosis or prescription or treatment of illness, physical damage or pain.

If you are concerned about a serious or urgent condition please see your GP.

A full copy of the Rolf Institute of Structural Integration Code of Ethics is available on request.

Rolfing Treatment is not a substitute for medical treatment

I understand the purpose of Structural Integration is to balance and align the physical body so that it is better supported and maintained by gravity in three-dimensional space. This is done through direct manipulation and education so that greater economy and freedom of body-movement is achieved.

I understand Rolfing treatment involves physical touch and the practitioner has explained the treatment and procedures involved. Respect for personal body privacy will be maintained at all times.

I am not expecting any healing influence on any illness.

I accept that 24 hours notice of cancellation of an appointment is required otherwise the full fee will be charged.

I am not suffering from addictions or illnesses that could be dangerous to myself or others, and I am not undergoing psychiatric treatment at the present time.

I accept that the Rolfing practitioner reserves the right to refuse or postpone treatment if he feels physically unsafe, or if he feels the client is suffering from the effects of alcohol or recreational drugs.

I have read the above (and the Data Processing Notice below) and I am willing to proceed with the treatment sessions at the agreed fee, and understand I can cease treatment sessions at any time subject to these terms.

Data Processing Notice

Any personal data we collect about you may include data relating to your name, address, date of birth, wider contact details and data relating to ‘health’ if applicable. We will process your personal data to allow us to provide you with our services, for statistical analysis and to assess your suitability for our services.

Your data may also be used to manage future communications between us including about our services, e.g. promotions, events or newsletters. You can opt out from receiving communications about services at any time by emailing info@rolfing-james.co.uk or by writing to us.

We will only use your data for the purpose for which it was collected. We will only grant access to or share your data with authorised partners, third parties and our market service providers such as insurers and where we are required or entitled to do so by law under lawful data processing.

*Electronic signatures are valid and fully enforceable as if they were wet signatures.