SESSION BOOKED!

WHATS NEXT?

1. Complete Pre-Assessment: To ensure that your session is personalised to address your specific goals, please provide the required information via the secure form below.

2. Check Your Inbox: Keep an eye on your email for your booking confirmation and the Zoom link you’ll need to join the meeting for your session. If you don’t see the email in your Inbox, remember to check your junk, spam, and promotions folders.

COMPLETE YOUR PRE-ASSESSMENT FORM

Pre-Assessment

Full Name

Address

Date of Birth

Contact Phone Number

Email Address

Occupation

Relationship Status

GP Surgery

Non-UK please type N/A)

GP Contact Number

Non-UK please type N/A)

Emergency Contact Number

Relationship of Emergency Contact

Reasons for services by Authentic Health

Lifestyle Section - Fluid intake per day (type)

Alcohol intake (units per week & types)

Have you consumed alcohol in the past 24 hours?

Yes

Do you consider your diet to be healthy?

Do you take any food or vitamin supplements? If so, what?

Do you smoke? If so, how many per day?

Do you use Recreational Drugs? If so, have you taken any drugs in the past 24 hours?

Exercise What types, how often and for how long?

Hobbies

How do you relax & do you find it easy or difficult?

How well do you sleep?

Good

Average

Restless

Poor

Average hours slept per night?

Do you suffer from...

Depression

Tension

Anxiety

Stress

If you suffer from those conditions, how do they affect you?

Medical History Section - List All Current Medical Conditions

Is your GP aware of those conditions?

List your prescribed medications

Have you had any operations in the past? If so, please list these here

Have you had any X-rays/Tests in the last 3 years? If so, when & what for?

Is your GP aware of those conditions?

Yes

Relevant Medical History

Are you pregnant? If so, how many months?

Are you menopausal? If so, please list symptoms

Do you have regular periods?

Date of last period if known

Please confirm you have any necessary emergency intervention medication with you: Inhaler, EpiPen, Heart Spray/Meds etc?

Yes

If you have any necessary emergency intervention medication with you, please list those

Are you receiving any other treatment holistic or allopathic?

How do you rate your current well-being Physically (0-100%)?

How do you rate your current well-being Mentally (0-100%)?

I confirm that the information provided above is correct and that to my knowledge I have not withheld any information that may be relevant to my treatment.

I confirm

I willingly and voluntarily consent to participate in services provided by Authentic Health. I understand and agree to the following terms.

I consent

I willingly and voluntarily consent to participate in services provided by Authentic Health. I understand and agree to the following terms: I have been provided with information regarding the nature, purpose, risks, benefits, and alternatives of the services offered by Authentic Health. I am aware that the services offered by Authentic Health involves a holistic approach to well- being and may include addressing physical, emotional, and spiritual aspects. I voluntarily assume any potential risks associated with the services provided. I have had the opportunity to ask questions, and all my inquiries have been answered to my satisfaction. I understand that the services provided by Authentic Health are complementary to, and not a substitute for, conventional medical treatment. I understand that all information shared during the sessions will be kept confidential unless there is a legal obligation to disclose such information. I authorise the release of my information to practitioners involved in my care. I understand that the outcomes of the services offered by Authentic Health may vary, and there are no guarantees of specific results. I agree to adhere to the payment and cancellation policies outlined by Authentic Health. I understand that fees are to be paid as per the agreed-upon terms. I acknowledge and agree that cancellations made within 24 hours before the scheduled booking time will not be eligible for a refund. No refunds will be provided once the services have commenced. I consent to the use of my photographs or videos for services and educational purposes only. I understand that additional consent is required for the use of my photographs or videos for marketing purposes. In the event of an emergency or if I require immediate medical attention, I authorise Authentic Health to contact my emergency contact and/or seek appropriate medical assistance on my behalf. By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions outlined in this consent form.

Please denote your Signature by Typing your Full Name

Captcha

If you are human, leave this field blank.

Have Any Queries?

We’re Here to Help!

Reach out to us! Our dedicated team is ready to provide the answers you need to make informed decisions about your authentic health journey.

GET IN TOUCH