Subject

Your Name (required)

Company Name (optional)

Date (if using Firefox enter date in format YYYY-MM-DD)

Birthdate (if using Firefox enter date in format YYYY-MM-DD)

Address

Mobile

Email

Occupation

GP Surgery

Please complete all questions, providing details where relevant

Are you currently seeing a GP/Health Practioner? YesNo

Current health issues/conditions for which you are currently taking prescribed medication? YesNo

Is there any chance you could be pregnant? YesNo

Do you have any allergies? YesNo

Are you currently suffering from a fever or illness? YesNo

Do you suffer from diarrhoea or constipation? YesNo

Do you suffer from DVT or Thrombosis? YesNo

Have you been diagnosed with or have a history of:

Epilepsy? YesNo

TB/Osteoporosis? YesNo

Headaches / Migraines? YesNo

Skin conditions - including bruising/scars etc...? YesNo

Any other chronic/serious illnesses (present or historic)? YesNo

Have you had any recent or past operations/surgery? YesNo

Is there anything else regarding your health that you feel may be relevant, not mentioned above? YesNo

EXERCISE PER WEEK:

AREAS OF TENSION/INJURIES:

Potential contra-indications for massage above are in bold and require your GP's consent prior to your massage session. Please tick the relevant box below to confirm your understanding and acknowledgement of contra-indications and your personal health.

YesNo I confirm that I have obtained GP written or verbal consent to receive massage/reflexology/beauty in light of the health issues stated above;
or
I am fully aware that the medical conditions stated above in bold are considered contra-indications to massage/reflexology/beauty, and until I obtain the requested consent from my GP, I hereby take full responsibility in my participation of the treatments and any effects or harm that may result from all therapy sessions with Target Therapies.

On signing this document, you agree to refrain from consuming alcohol or drugs within 12 hours of a treatment, and agree to update the therapist of any changes to your health prior to each session.

CLIENT SIGNATURE (To confirm details are true.)

Client Declaration
I have completed a pre-treatment consultation and I confirm that through the information provided by the therapist, and answers to my questions, that I have full understanding of the treatment procedure and relevant contraindications. On the date of signing, I confirm that all the personal and medical information about myself and my current and historical health has been disclosed fully and correctly, and that I have not omitted any information concerning my health or state of wellbeing. I confirm that should my medical circumstances or health change in any way between treatments, I will inform my therapist(s) prior to any subsequent treatments, and consequences resulting from the failure to do so is wholly my responsibility.

I confirm my understanding that there is a possibility of some physical discomfort for a short time during, and for short periods following treatments, as my body adjusts to the treatment being received.

I confirm and consent to the details of this consultation form being stored and used by Target Therapies to contact me regarding their services and for personal data and ongoing therapy notes to be accessed by those therapists working for Target Therapies.

I confirm my understanding that my therapist is not qualified to diagnose illness, disease or any other physical or mental disorder and that massage therapy is not a substitute for a qualified medical examination, diagnosis or treatment.

Should my therapist believe there is a particular health issue or contraindication, I agree to obtain my GP/Practitioner's consent for therapies to continue, and understand that it may be necessary to delay treatments with Target Therapies until this is achieved. In agreement with my medical professional, my therapist will then devise a treatment strategy around this diagnosis as appropriate.

I confirm that my participation in the treatment is undertaken freely and is my choice.

I hereby confirm that my participation in the treatment is undertaken freely and is my choice.

I hereby confirm that i fully understand and accept the contents of the Client Declaration.

Client's Name (block capitals)

Client's Signature
Date (if using Firefox enter date in format YYYY-MM-DD)

Any other comments