Pre-Treatment Consultation Form

Please complete this form before your first treatment. Please contact me if you have any questions about filling it in.

Name(Required)

First Last

Email(Required)

Address(Required)

Postcode

Phone number(Required)

Your preferred phone number

Additional Phone number

Alternative phone number (optional)

Date of Birth(Required)

Gender(Required)

Female

Male

Other

Occupation

Doctor's name and surgery(Required)

Medical History

Please list any relevant medical history and all medication you are currently taking. Give details of any conditions stating the area affected. If you are not sure whether something is relevant please include it or contact me to discuss.

Have you had massage before?

Have you had a massage before with any other therapist, including spa treatments?

Other current treatments

Are you currently being treated by another health professional? Eg. Chiropractor, Osteopath etc.

General health

Do you suffer from any of the following conditions

Allergies

Please give details of any allergies

Presenting Problem(Required)

Let me know where you feel your pain or issue is. What caused your problem?

Your data will be treated confidentially and only used in connection with your treatment. Please see our privacy policy for more information.

Tel: 07793 532911

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Telephone: 07793 532911