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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 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
  • :
    • 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:
      • Date:

      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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