Calm Consultation Form

Calm Consultation Form
Please complete this Consultation Form as fully as possible, this ensures we have all the relevent information regarding your health history and can tailor your treatment or suggest an alternative treatment.

We cannot carry out any treatments without this being completed.

If you are feeling unwell please rearrange your appointment as soon as you can, please be aware of our cancellation policy.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Post code
Phone Number

Area CodePhone Number
Mobile
Email
example@example.com
Date of birth
Medical History

Type a question

	Yes
Heart Conditions/pace maker
Severe circulatory disorders/DVT
Diabetes
Skin Disorders
Kidney Problems
Swelling/Odema
Haemophilia
Cancer
Limitation of body movement/Arthritis
Hormone imbalance
Stroke
Claustrophobia
Hepatitis
Metal pins/plates/piercings
Recent scar tissue/Surgery
Respiratory Problems
Allergies
Are you pregnant (females)
Epilepsy
High or Low Blood Pressure
Operations in the last 6 months
Any Other Medical conditions
Medications

Additional Information

Details of any health issues.
Any additional information
I declare that the above information I have given concerning my health is correct.
Signature

Clear
Date

MonthDayYear
Date
Data Protection & Privacy
We are commited to protecting your privacy. We take special precaustions with your sensitive data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data. By signing this document you give your consent to Calm Treatment Rooms and Calm Organic Beauty to use it for the purposes of your business with them.
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