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HOME
TREATMENTS
TRAINING
ABOUT

BLOG
GIFTS
BOOK
- BOOK A TREATMENT
- NEW CLIENT

BOOK A TREATMENT

NEW CLIENT

CONSULTATION FORM

PLEASE ONLY COMPLETE THIS FORM, AFTER YOU HAVE MADE AN APPOINTMENT WITH ME

Please complete and send the form below – confidential:

NEW CLIENT

07765011554

fyldeholistictherapies@outlook.com

NEW CLIENT SIGN-UP

Full Name

Phone

Field label

Occupation

Address

Gender:

Male

Female

Other

(ladies only) Are You Pregnant?

Yes

Stress Level (Low - High):

1 (low)

5 (high)

Energy Level (Low - Ligh):

1 (low)

5 (high)

Cigarettes:

Alcohol:

Sleep Patterns:

Weekly Exercise:

Hobbies And/Or Interests:

Do You Have Any Allergies?

Yes

Allergies:

Are You Currently Taking Any Medication?

Yes

Medication:

Problematic Areas On Your Body:

Free Text

Please Tick if You Suffer From or Have a History of Any of The Following:

Suffer From or History Col#1:

Recent Accident Or Injury

Recent Operations

Back Problems

Neck Problems

Osteoporosis

Arthritis

Artificial Joint

Broken/Fractured Bone

Suffer From or History Col#2:

Headaches/Migraines

Dizziness

Varicose Veins

Recent Swelling/Oedema

Infectious Diseases

Hernia

Current Fever

Current Diarrhoea

Suffer From or History Col#3:

Heart Disorders

High or Low Blood Pressure

Thrombosis/Embolism

Asthma

Diabetes

Epilepsy

Cancer

Nervous System Dysfunction

Suffer From or History:

Do You Have Any Other Medical Issues/Conditions or Surgical History?

Yes

Medical Issues/Conditions or Surgical History:

Have You Had Traditional Thai Massage Before?

Yes

Thai Massage Expectations:

Are You Currently Seeing A Chiropractor, Physical Therapist, Physician?

Yes

Chiropractor, Physical Therapist, Physician Help:

Spacer

Full Name:

The Client...

The client understands and agrees that they will provide the Therapist with complete and accurate health information. I understand that massage therapy is designed to be an ancillary health aid and is not suitable for primary medical treatment for any condition.

Clause #1:

1). I the Client and Therapist have discussed the potential benefits and possible side effects of massage therapy and have agreed upon a course of focussed attention and manually therapy for predetermined goals of stress reduction, relief of muscular discomfort and/or general health. I have been given an opportunity to ask of the Therapist and have received all requested information.

Clause #2:

2). I the client understand that the unclothed body will be draped at all times for warmth, sense of security, and as a mark of massage therapy professionalism. I agree to immediately inform the Therapist of any unusual sensation or discomfort so that the application of pressure may be adjusted to my level of comfort. I understand that massage therapy is not sexual in any manner and that any illicit or suggestive remarks of behaviour on my part will result in an immediate termination of the therapy session. I understand that payment will be expected in full; regardless if the massage is complete or not.

Clause #3:

3). I the Client hereby assume full responsibility for receipt of the massage therapy, and release and discharge the Therapist from any and all claims, liabilities, damages, actions, or causes of action arising from the therapy received hereunder, including without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist, to the fullest extent allowed by the law.

Clause #4:

4). I the Client in signing this consent for Therapy and Waiver liability (“Consent”), understands and agrees that this Consent will apply and govern the current and all future therapy sessions performed by the Therapist at Fylde Holistic Therapies

Clause #5:

5). We will always store your personal details securely. We’ll use them to provide the service that you have requested and communicate with you in the way(s) that you have agreed to. Your data may also be used for analysis purposes, to help us provide the best service possible. We will never share your details with third parties unless required to do so by law. For full details visit please speak to our Therapists

Clause #6:

6). I the Client will inform the centre / therapist if there are any changes to the above information.

Clause #7:

7. I, the client understand that if I am unable to keep my appointment I must give 24 hours notice or I will be charged a 100% cancellation fee. If I arrive late for my appointment, treatment may be refused or shortened and I will be charged the full fee.

Sign-up:

If you would like to hear more from us about new therapies, offers and discounts please tick

Signature:

Signed Date:

Thank you for signing up as a new client with us.

We will get back to you as soon as possible

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AREAS COVERED

Mobile Holistic Therapy treatments for the Fylde Coast (FY postcodes only) area, Lancashire, North West, UK

fyldeholistictherapies@outlook.com

OPENING HOURS

Mon - Thu: 9:00 am - 4:00 pm
Fri - Sun: Closed