Baseline form

Please answer honestly about how things are at this moment. There are no right or wrongs.

To be completed by a parent or caregiver if the child is under 16 years.

Child's full name

Child's date of birth

This helps us match you to the right record.

I am this child's parent or legal guardian with parental responsibility, and I agree to their answers forming part of their chiropractic clinical record, as set out in the Privacy policy and Terms & conditions

How we use this information

Lumina Chiropractic is the data controller for the information given here. Your child's answers, including health information, form part of your child's chiropractic clinical record and are held securely in Practice Hub, our practice software, alongside their notes and files.

We use your child's answers to plan, deliver and review care. We process this as part of our agreement to provide you with care (UK GDPR Article 6(1)(b)), and health information, which is special category data, because it is necessary for the provision of health care by a registered health professional bound by a duty of confidentiality (Article 9(2)(h)).

In line with General Chiropractic Council guidance, clinical records are kept for a minimum of eight years after the last appointment, and for patients under 18 until age 26, whichever is longer. We never sell your child's answers or use them for marketing.

You can ask to see, correct, restrict or object to the use of this information by emailing hi@luminachiropractic.co.uk or calling 07301 366 743. You may also complain to the Information Commissioner's Office at ico.org.uk. Full details are in our privacy policy and terms & conditions.