As Chartered Physiotherapists our Pilates instructors have a legal obligation to collect and process the information asked in section 1 to comply with the requirements of their professional registration and therefore we do not require your consent for the first section of this form. Where information to be supplied is voluntary or where we do need consent this is identified. The information provided will be uploaded onto our secure software database and used for the purpose of maintaining appropriate contact details and for your own safety and well-being.
Date of Birth:
Prescribed Pilates is Physiotherapy led. Our Physiotherapists can modify any exercise to help to address any medical issues or pain that you may have. Our Pilates can simply be a form of exercise or as a method of managing a health problem. If you do have an active injury or medical problem then we strongly suggest a 1:1 session to assess this thoroughly. You must declare below any problems that you have had in the past or that you are currently experiencing problems with so that we can make the necessary adjustments within the class.
1. We need to know if you have any medical history so please complete the following honestly, giving details below where appropriate.
Have you had heart trouble or a heart defect?Have you ever had pain in the chest when you undertake physical activity?Do you suffer from regular headaches?Have you ever lost balance because of dizziness?Have you ever lost consciousness or regularly felt faint or dizzy?Do you suffer from either high or low blood pressure?Have you had any major surgery in the last 10 years?Have you had any minor surgery in the last two years?Do you have asthma, diabetes or epilepsy?Are you taking any regular medications?Have you been pregnant in the past six months, or are you pregnant now?
Please use the space below to give details of any of the above:
2. Prescribed Pilates is often used to help manage a joint or muscle problem. Please give details of any of these problems that you may have now or have experienced in the past.
Have you ever been diagnosed with any of the following:
Osteoarthritis?Rheumatoid arthritis?Osteoporosis or Osteopenia?Hypermobility Syndrome? (excessively flexible joints)Any other bone or joint problem?Any other muscular problem?Any other condition?
Please use the space below to give details of any of the above, stating how they may affect your ability to exercise.
3. Are there any movements that cause you pain?
The following information is voluntary and you do not have to complete it. However, we have a legitimate interest in requesting this data and we believe it will assist in providing the best treatment to you.
1. Do you have any experience of Pilates?
2. Why have you decided to start Pilates with KTB?
3. What do you hope to achieve from your Pilates?
Pilates can improve pain caused by repetitive and poor postures. For us to understand what could influence your posture please answer the following:
4. What is your occupation?
5. Are you involved in any other activities?
6. Do you have any hobbies?
7. How did you hear of KTB Prescribed Pilates?
Consent to Pilates at KTB
• I confirm the information I have given is accurate and hereby give consent to receiving Pilates based physiotherapy from KTB Rehabilitation on this and any subsequent occasion.
• I understand that the classes will always be taken by a Chartered State Registered Physiotherapist.
• I understand that it is my responsibility to inform the Physiotherapist taking my class of any change in my medical or health status and also of any pain or discomfort experienced during a class.
• I understand that a 1:1 session is recommended before joining a class to fully discuss and assess any medical, joint or muscular problem that I have disclosed. I understand that my medical history will be treated with the strictest of confidence.
Private Patients Self Funding their Appointments/Pilates
• I have been advised of the current fees charged by the centre at each clinic and understand the payment terms.
• I agree to pay at the time of booking each appointment.
Non Attendance Policies
• Over 24 hours notice to cancel - no charge
• Less than 24 hours notice to cancel - £15 fee 30 min appt; £30 60 min appt
• Less than 24 hours notice on more than two occasions - full fee
Prescribed Pilates Classes
• Our Pilates classes are paid for in advance for a six week course. You will reserve a place on a set session and will be expected on that session each week from the date that you pay.
• Allow 24hrs cancellation notice. We do have a flexible policy whereby if you are unable to attend your booked session you can inform reception and change this class to another time within your six weeks according to availability.
The Data Protection Officer with responsibility for monitoring this privacy notice is Katie Ballard.
We may collect the following information:
• Contact information including email address
• Demographic information, such as postcode, preferences and interests
• Personal information including detailed medical information for the purposes of providing treatment.
• Other information relevant to client enquiries
Collecting this data helps us to ensure that we can provide a safe and beneficial service to our clients.
Specifically, we may use data:
• To ensure that we have the information required to provide safe and appropriate physiotherapy or Pilates service.
• To handover to members of the team who may be involved in the care pathway.
• To ensure that we meet the statutory requirements for the HCPC governing physiotherapists.
• To contact you via email, telephone or email regarding your inquiry.
– We will never lease, distribute or sell your personal information to third parties unless we have your permission or the law requires us to do so.
– Information is not stored for the purpose of sending automated emails regarding our services.
Through agreeing to this privacy notice you are consenting to KTB Rehabilitation processing your personal data for the purposes outlined. You can withdraw consent at any time or if you would like to discuss anything in this privacy notice, please contact Katie Ballard at KTB Rehabilitation Westgate House Spital Street Dartford DA1 2EH or by email [email protected]
If you have a concern about the way we are collecting or using your personal data, you should raise your concern with us in the first instance or directly to the Information Commissioner’s Office at https://ico.org.uk/concerns/
Access to your information
Your rights as a data subject
At any point whilst we are in possession of, or processing your personal data, all data subjects have the following rights:
• Right of access – you have the right to request a copy of the information that we hold about you.
• Right of rectification – you have a right to correct data that we hold about you that is inaccurate or incomplete.
• Right to be forgotten – in certain circumstances you can ask for the data we hold about you to be erased from our records.
• Right to restriction of processing – where certain conditions apply you have a right to restrict the processing.
• Right of portability – you have the right to have the data we hold about you transferred to another organisation.
• Right to object – you have the right to object to certain types of processing such as direct marketing.
• Right to object to automated processing, including profiling – you also have the right not to be subject to the legal effects of automated processing or profiling.
To access what personal data is held about you, identification will be required. One piece of photographic ID and one item of supporting documentation such as a utility bill or bank letter will be required. Requests should be made to Katie Ballard.
To prevent unauthorised disclosure or access to your information we have implemented strong physical and electronic security safeguards.
Our website is scanned on a regular basis for security holes and known vulnerabilities in order to make your visit to our site as safe as possible.
Your personal information is contained behind secured networks and is only accessible by a limited number of persons who have special access rights to such systems, and are required to keep the information confidential. All our data processors have been vetted to comply with GDPR safety regulations.
Only staff engaged in providing your treatment will have access to your patient records, although our administration team will have access to your contact details so that they can make appointments and manage your account.
KTB Rehabilitation will not disclose your Personal Information unless compelled to, in order to meet legal obligations, regulations or valid governmental requests.
Our website may contain links to other websites. Please note that we have no control of websites outside the KTB Kids domain. If you provide information to a website to which we link, we are not responsible for its protection and privacy.
Always be wary when submitting data to websites. Read the site’s privacy policies fully.
KTB Rehabilitation will process personal data during the duration of any treatment and will continue to store only the personal data needed for eight years after the contract has expired to meet any legal obligations. After eight years, all personal data may be deleted, unless basic information needs to be retained by us to meet our future obligations to you, such as erasure details. Records concerning minors who have received treatment will be retained until the child has reached the age of 25.
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