SFH IC and Health Dec - Jayne Sarah Therapies

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Age*

How did you hear about Jayne Sarah Therapies?

If a person told you about me, please name them:

GDPR*

I understand that any documentation stored about my therapy will be in accordance with GDPR as detailed in Jayne Sarah Therapies Privacy Policy

How may I respond to your enquiries?

How may I contact you with appointment reminders, rearrangements and cancellations?

Would you like me to email you with general information about Jayne Sarah Therapies, including special offers?

Would you like me to email you vouchers?

Vouchers include Gift vouchers, Birthday vouchers, Christmas vouchers, Thank you vouchers, Feedback vouchers and others.

Please can I email you a Feedback Form once you have completed your sessions?

How can I contact you with aftercare advice and relevant information?

Health Declaration*

Please confirm the following statements. If you cannot agree to all of them, please detail below.

I understand that I must not attend an appointment with Jayne Sarah Therapies if I have any infectious or contagious illness.
I have not tested positive for COVID-19 in the last 14 days.
I do not live with anyone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days.
To my knowledge, I have not been in contact with anyone with symptoms of Covid-19, such as fever, a new persistent cough or loss of taste or smell, in the last 14 days.
If either I, or someone I have been in contact with, tests positive for Covid-19 I will inform you.
I understand that by attending future sessions, I agree to all of the above on an ongoing basis and will cancel any future sessions should my health be compromised beforehand.

If you are unable to confirm any of the health statements above, please provide further information here:

AGREEMENT FOR THERAPY*

I understand that I must give at least 24 hours notice to cancel treatments with Jayne Sarah Therapies, otherwise I will be charged a full price cancellation fee. (The only exception to this is a sudden onset of a contagious or infectious illness.)