Consultation Form

Name*

Last name*

Your email*

Date of Birth*

Emergency Contact*

Which treatment did you schedule?*

Reflexology

Manual Lymphatic Drainage (MLD)

Massage Therapy

Unsure (Please advise)

Medical History - Do you currently have or have you ever had any of the following?*

High Blood Pressure

Low Blood Pressure

Heart Condition

Diabetes

Cancer

Lymphoedema

Blood Clots (DVT)

Stroke

Epilepsy

Asthma

Arthritis

Osteoporosis

Fibromyalgia

Autoimmune Condition

Skin Condition

Varicose Veins

Infectious Illness

Pregnancy

None of the above

Any other medical conditions?

Are you currently taking any medication?*

Do you have any allergies? (Including oils, latex, adhesives, medication)*

Contraindications - Please tick any that apply:*

Fever or infection

Cold or Flu

Contagious Skin Condition

Open Wounds

Acute Inflammation

Deep Vein Thrombosis (DVT)

Active Cancer Treatment

Recent Surgery

Severe Heart Condition

Kidney Disease

Uncontrolled High Blood Pressure

None of the above

GP Consent - Some medical conditions may require written permission from your GP or Healthcare professional before can proceed*

GP consent not required

GP consent received

GP consent required

Female Clients - What is the date of your last menstrual period?

Female Clients - Are you pregnant? If yes, how many weeks?

Reason for the appointment:

What are your goals and expectations for this appointment?

Client Informed Consent*

I confirm that: - I have provided accurate and complete information regarding my health - I understand that I must inform my therapist of any changes to my health or medication before each treatment - I understand that reflexology, manual lymphatic drainage and massage are complimentary therapies and are not intended to diagnose, treat, or cure medical conditions - I understand that treatment may be modified or declined if it is not safe to proceed - I consent to receive treatment and understand I may withdraw my consent at any time.

Declaration*

I declare that the information I have provided is true and complete to the best of my knowledge. I understand that withholding medical information may affect the safety and effectiveness of my treatment. I consent to the collection and storage of my personal information for treatment records in accordance with UK GDPR and data protection legislation.

Photography Consent*

I consent to photographs being taken of the treated area for documentation only seen by the therapist and myself

I consent to those photographs being used anomalously for or promotional purpose by my therapist

I do not consent to any photographs being taken

Marketing

I would like to receive news, offers, and marketing updates from Melinda Moments via email. I understand I can unsubscribe at any time.

Thank you for completing the form before your first consultation!

Client Intake & Consultation Form

Reflexology - Manual Lymphatic Drainage - Massage Therapy

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