Client Consultation Form
Pre-treatment Consultation Form @SJTherapies Please fill out the following form BEFORE your FIRST Massage/Hypnotherapy Treatment. All information follows strict GDPR guidelines, protected & stored privately.
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Name
Which are your preferred services at SJTherapies?
Cellulitis, Contagious Disease, Imminent Medical Tests, Thrombosis/DVT, Phlebitis, Aneurism, Severe Undiagnosed Headaches, Undiagnosed Illness, Stroke, Gangrene, Cut/dead nerve conditions/damage of Neuropathy, Diabetes, Skin conditions worsened by massage or heat, Pregnancy (first trimester or if history of miscarriage, no abdomen massage at any time, post birth up to 3 months) Prescription medications sensitive to heat or massage stimulation, Heart Disease, Varicose Veins, Immunity diseases whilst undergoing treatment, Elderly or young children sensitive to heat of stones, Inflamed organs, Cancer, Cancer’s of bone and Hodgkin’s disease, Within 6 months of radiotherapy, chemotherapy or surgical operation, Cardiovascular issues, Inflammatory conditions, Epilepsy, Mental disorder, Diagnosed Depression.
Do you currently have: Recent fractures, cuts, open wounds, broken skin, abrasions, burns, recent scar tissue, severe varicose veins, contraceptive implant, pacemaker, suspected or real thrombosis, acute rheumatoid arthritis, undiagnosed lumps.
Add details here if applicable…
STATEMENT OF DECLARATION:
I do not suffer from any medical problems other than the ones listed on this form. I agree to undertake the treatment and I will seek medical approval from my GP should the situation with my health change. I understand that my therapist is qualified in the services advertised. I understand that my therapist is covered with public liability insurance as well as Therapy Insurance and a member of relevant associated bodies. ​ Should I become positive with COVID-19 prior to our appointment, I will re-arrange when I can confirm clear and negative results. I understand Sam operates a 48 hour cancellation policy and I will adhere to this to the best of my ability.
AGREEMENT
I have read, understood and agree to the Terms and Conditions & Privacy Policy, including GDPR, at: https://sjtherapies.com/privacy-policy-terms-conditions
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