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
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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 (including to cleaning products)?:
    • 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?:
    • Date:
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    Calico Pregnancy Massage  Consultation Form