CLIENT INTAKE

Pre-Appointment Health & Consultation Form

Thank you for booking with DL Performance Therapy.

Please complete this short form before your appointment. This helps Derek understand your goals, medical history, and any areas that may need attention before your treatment.

All information is treated confidentially and used only for treatment preparation, client care, and (with consent) future communication.

Personal Details

Full Name *

Date of Birth

Mobile Number *

Email Address *

Occupation

Emergency Contact Name

Emergency Contact Number

Appointment Details

Which location are you attending? *

What is the primary reason for your appointment? *

Briefly describe the issue, pain, injury, or treatment objective

How long have you been experiencing this issue?

Less than 1 week 1–4 weeks 1–6 months More than 6 months

How Did You Hear About Us?

How did you hear about DL Performance Therapy?

Treatment Consent

I confirm that the information provided is accurate to the best of my knowledge.

I understand that massage, soft tissue therapy, cupping, taping, and related treatments are not a substitute for medical diagnosis or treatment.

I understand that I should inform Derek of any changes to my health before treatment.

I agree and consent to treatment based on the information provided *

Marketing Preferences (Optional)

Derek will always contact you about your own appointments — confirmations, changes and treatment follow-up. That is separate from marketing and does not require your consent here.

Separately, DL Performance Therapy may occasionally share appointment availability, recovery tips, promotions, new services and educational content. This is entirely optional and nothing is selected by default. Would you like to receive occasional updates?

Yes, by Email Yes, by SMS/WhatsApp Yes, by both Email and SMS/WhatsApp No

Privacy Notice

Your personal information will only be used by DL Performance Therapy for treatment preparation, client care, appointment management, and, where consent is provided, marketing communications.

Your information will not be sold, shared, or provided to third parties for marketing purposes.

You may request removal of your data or withdraw marketing consent at any time.

I have read and understood the privacy notice *

Digital Signature

Digital Signature / Full Name *

Date *

Need help completing this form? Message Derek

Have a question? Message Derek directly