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Calico Massage Appointment Consultation Form

Please read the following before completing and submitting this consultation form within 48 hours of your appointment. Many thanks


        

By submitting this form I confirm that the information provided is correct and I consent to having the massage therapy treatment. I confirm that my records can be retained in line with legal requirements (see privacy information below). I consent to my details beign shared with the NHS Test and Trace service should they be required.

 

Calico Consultation Form
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    • Is your general health good?:
    • Do you have any ongoing illnesses or diseases?:
    • Do you have any contagious or infectious diseases or illnesses (including skin)?:
    • Are you taking any medication?:
    • Do you have any allergies?:
    • For women, are you pregnant?:
    • Are you having a high or low risk pregnancy?:
    • For women, are you postnatal?:
    • If postnatal, are you comfortable lying on your stomach and back for your massage?:
    • Have you completed and submitted the Covid-19/coronavirus pre-assessment form?:
    • If not, please click on the Covid-19 link at the top of the page to access the pre-assessment screening form. Thanks:

      PRIVACY INFORMATION: Your information is required and retained to ensure a safe and effective massage therapy treatment, for appointment arrangements and for adminstration purposes. It is kept confidential at all times. There may be a rare instance where there is a legal requirement for us to pass on your information without your consent. You have the right to ask for a copy of all records about you at any time or with draw this consent at any time. Your information is stored safely and securely and retained in line with the therapist's insurance company's requirements and will never be sold to a third party.   

       

       

       

       

       

       

       

       

       



       Working in and around the Leeds and Bradford area and from a treatment room in Leeds, Calico Pregnancy Massage offers therapeutic antenatal and postnatal massage treatments. Please just contact me for a chat to find out more or to make an appointment. Privacy Policy.

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