JemmaCo Medical / Treatment Update Form
If you would like to make any changes to your treatment or make us aware of any new conditions affecting you then please fill out this form.
Full Name
*
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Any changes to your medical History?
Please make us aware if your health has changed in any way and details of how this could affect the treatment
Changes to your treatments
Anything you would like to change in your massage treatment due to health or anything else
How do you wish to feel from your treatment?
Harmonised
Revitalised
Relaxed
Details of physical condition: please specify areas on your body and the type of discomfort experiences.
For example: Sharp / Pulling / Tender / Intense / Shooting / Aching
Please state your main reason for treatment
physical support
mental health support
Both
Declaration
*
I agree to the above information being accurate and to the best of my knowledge
I agree I am fit and well to attend my appointment
I agree I have taken my temperature prior to treatment and it is below 37 degrees
Signature
*
Submit
Should be Empty: