Client consultation form

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Consultation FormPlease fill this in honestly and to the best of your knowledge. All information given is treated with the upmost confidentiality and is for your Independent therapist to ensure the treatment is safe and suitable for you.
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Full name* This field is required.
First Name
Last Name
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Date* This field is required.
Date
Day
Month
Year
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Treatment required
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Are you taking any form of medication?* This field is required.
YESNO
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If yes, please give details:
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Ok
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Have you taken any drugs or alcohol in the last 24 hours?* This field is required.
YESNO
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Are you pregnant?* This field is required.
YESNO
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How are your energy levels?* This field is required.
Low
Medium
High
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Have you had any treatments before?* This field is required.
YESNO
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Do you suffer any allergies?* This field is required.
YESNO
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Anything else you feel we should be made aware of?
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Ok
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High or low blood pressure?* This field is required.
YESNO
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Varicose veins?* This field is required.
YESNO
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Heart problems?* This field is required.
YESNO
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Epilepsy or Diabetes?* This field is required.
YESNO
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Cancer?* This field is required.
YESNO
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HIV or Aids?* This field is required.
YESNO
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Any other skin condition we should be made aware of?* This field is required.
YESNO
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If yes, please provide details:
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Small
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Ok
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What are the main reasons for your treatment today? e.g To relax, for a specific issue.* This field is required.
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Small
Ok
Ok
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What areas would you like concentrated on during your treatment today? e.g, back/ legs or if a facial, eyes/forehead.* This field is required.
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Ok
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What pressure would you like the therapist to use?* This field is required.
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Client Waiver. Please read each of the statements below to confirm your understanding and acceptance:

⦁ I understand that InterCity Mobile Therapists Ltd is simply acting as an agent of the Independent Therapist in having made the booking for the Treatment, and that the Independent Therapist is Solely responsible for the Treatment.
⦁ I understand and agree that my contract with the treatment is with the Independent Therapist.
⦁ The Independent Therapist offers Treatments through InterCity Mobile Therapists and has to be rebooked through their software and booking system.
⦁ I understand my treatment today is not a substitute for medical care and that I have informed my Independent Therapist prior to my treatment of all known medical conditions and injuries.
⦁ I understand that my Treatment is of a professional, therapeutic basis and is in NON-SEXUAL in nature.
⦁ By signing this waiver, I hereby release my Independent Therapist from any and all liability past, present and future, relating to Treatments, Massage or any Body work.
By signing below, I also consent to the processing of all my information.
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Signature* This field is required.
Should be Empty: