appointment consultation form

By submitting this form I confirm that the information provided is true and I have not withheld any information concerning my health. I will keep you updated on my health should there be any changes to the answers given. I undersstand there is a possibility I may experience some minor reactions as my body adjusts to the treatment.

I understand that this treatment is not a substitute for medical examination, diagnosis or treatment and the therapist does not diagnose illness, disease or other condition. While I recognise that all due care will be taken by the therapist, I am aware that my participation in the treatment is voluntary and I give my 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.

For pregnant clients: I understand that at this time I am considered to be in the Government's Covid-19 'clinically vulnerable' category and therefore at greater potential risk. I understand that there may be an additional risk to me by having a close-contact therapy and consent to having the treatment on this understanding.

Calico Consultation Form

Full Name:*
Address:*
Postcode:*
Email address:*
Contact phone number:*
GP Surgery Name:*
:
Is your general health good?:
- Yes
- No
If no, please give details. :
Do you have any ongoing illnesses or diseases?:
- Yes
- No
If you do, can you please provide more information?:
Do you have any contagious or infectious diseases or illnesses (including skin)?:
- Yes
- No
If you do, can you please provide more information?:
Are you taking any medication?:
- Yes
- No
If yes, please list:
Do you have any allergies?:
- Yes
- No
If yes, please give details:
For women, are you pregnant?:
- Yes
- No
- Not applicable
If yes, how many weeks pregnant are you?:
Are you having a high or low risk pregnancy?:
- High risk
- Low risk
- Not applicable
If high risk, please give details (in many cases this won't prevent you from having a treatment and is for my information when treating you):
For women, are you postnatal?:
- Yes
- No
- Not applicable
If you are postnatal, how many weeks/months?:
If postnatal, are you comfortable lying on your stomach and back for your massage?:
- Yes
- No
- Not applicable
What is the main reason for wanting a massage (e.g. relaxation, general pain relief, injury or pain in a specific area)?:
Is there any other information that you'd like me to be aware of?:
Have you completed and submitted the Covid-19/coronavirus pre-assessment form?:
- Yes
- No
If not, please click on the Covid-19 link at the top of the page to access the pre-assessment screening form. Thanks:
SIGNED (please add full name):*
Date:

Calico Pregnancy Massage Consultation Form

Working from a treatment room in Leeds and offering mobile appointments in Leeds and Bradford areas, Calico Pregnancy Massage offers therapeutic antenatal, postnatal and baby shower massage treatments. Please just contact me to find out more or to make an appointment.

Calico Massage Therapy Privacy Policy