New Patient RegistrationGavinHead_Shot

Thank you for choosing active X backs. I’m delighted to welcome you. Our aim is to provide you with great treatment, and the result you’re looking for. Our therapists adhere to the profession’s best practice code, and love what they do.

It would be normal for you to expect to remove items of clothing for your massage, but – by the use of towels – the clinician will aim to maintain your modesty at all times.

Thank you very much for taking the time to register online. The below form is confidential and all information will be held in the strictest confidence by active X backs. Please fill in all appropriate fields as this information helps us greatly to manage your health and to run our business efficiently in order to deliver the best service possible.  If you’re unable to register online prior to your first appointment, please arrive at the clinic ten minutes early in order to complete the form then.

We look forward to helping you to be active for life.

Warm regards,

Gavin Routledge
Clinic Director

Patient Information

  1. The therapist needs to know about your past and present health and you will be asked detailed questions about your complaint, medical history, general health and any medication you may be taking. You agree to provide this information.
  2. If you have any concerns at any time during the appointment, you agree to ask the therapist to stop the treatment and explain anything he/she does.
  3. To help us to understand and assess your condition, you may be asked to perform simple movements and further assessment may be conducted while you lie on an examination couch.  You agree to comply with this process.
  4. You may feel some discomfort for the first 24 to 48 hours after treatment, but if your discomfort feels excessive please telephone the clinic and talk to your therapist.
  5. You are ultimately liable for the cost of all treatment, services and items provided by active X backs and its agents.
  6.  In the event that we recommend exercises for you, you confirm that you have received confirmation from your doctor that you are in good enough physical health to undertake physical exercise without the guidance of your doctor, and that you do not experience pain in your chest when undertaking physical activity, you have not had any chest pain in the last month when not performing physical activity, you do not lose balance due to dizziness, you do not have a bone or joint problem which could be made worse by a change in your physical activity, and you are not aware of any reason that you should not engage in physical activity.
  7.  If you are taking any medication you will inform us prior to undertaking any physical activity.
  8. You consent to active X backs sharing your clinical notes with our other clinicians, for the benefit of your treatment/care.
  9. We use an online cloud-based clinic management and note-keeping system.  Your personal – including clinical – data will be held securely on EU-based servers, and we are registered with the Information Commissioner’s Office.  We will comply with the law in relation to this arrangement, and other than in our duty to comply with the law, no person or legal entity will be given access to any of your information unless it is with your express written consent.
Including postcode

A BIT MORE ABOUT YOU

If applicable

CLINICAL - When you come for your appointment, we want to spend as much time as possible delivering your treatment. Please answer the questions below to give us a head start.

If Other, please give details:

CONFIRMATION & CONSENT

By submitting this form you are certifying that your answers are correct and that you accept our terms as set out above.