New Client Consultation Form

Treatment Required

ReflexologyFacial TreatmentIndian Head MassageEar CandlingReiki

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

City

Country

Phone Number*

PrefixPhone Number

E-mail*

Occupation

Emergency Contact Name & Mobile*

Have you have a professional Massage / Reflexology/ Ear Candling treatment before?*

Are you currently attending a GP/complimentary therapist for any condition/treatment?

YesNo

GP / Therapist Name & Address and details of condition / treatment

Current Medication (incl vitamins):*

How did you hear about me?*

If Referral, please list name

If Other, please let me know where!

What is the objective of your visit (eg: relaxation, specific condition / pain)? *

Have you experienced any of these health conditions in the past or present?*

If you checked yes to any of these please provide further information. If not mark N/A*

Stress Levels at Home*

HighMediumLow

Stress Levels at Work*

HighMediumLown/a

Exercise / Hobbies?

Any known allergies (eg: aspirin, latex, nuts, essential oils)?*

Yes*No

*If Yes, please give details:

FEMALE CLIENTS ONLY: Are you / could you be pregnant*

YesNoN/A

Are you a smoker? *

YesNo

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo

Do you drink alcohol*

YesNo

What is your daily water intake (glasses / litres)*

Have you ever experienced claustrophobia? *

YesNo

Are there any other information you would like to make your therapist aware of? If yes, please give details:

Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 100%. I have reduced my capacity to see clients so this is vital to my business and to allowfor as many clkents to be seen.Suspected Covid-19 and severe pregnancy related issues are exceptions to this rule, but please do let me know asap.*

I understand the reservation and cancellation policies at Reflexology By Niamh Holistic Therapies

I knowingly and willingly consent to attending for a complimentary treatment during the COVID-19 pandemic.*

By checking this box I understand and accept this statement

CLIENT DECLARATION: I declare that the information I have given is correct and as far as I am aware I can undertake a treatment with out any adverse effects. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and I am willing to proceed. I understand that complimentary therapies do not substitute medical treatment. If I experience any discomfort during the treatment I will inform the therapist immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release the therapy from liability and assume full responsibility thereof. I understand that my therapist may require me to obtain permission from my doctor before my appointment.*

By checking this box I understand and accept this statement

I, Niamh Tansey t/a Reflexology By Niamh Holistic Therapies will occasionally contact clients to follow up on a session. I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for Renew Therapies to:*

Contact you about appointment and relevant follow up.Send occasional emails with news, special offers etc.

Signature*

Thank you for taking the time to complete this form - I look forward to seeing you soon.

Niamh

Reflexology & Massage Consultation Form

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