Client Consultation

General Health

The questions on this consultation form are to help guide me to offer you a tailored treatment and to help you on your path to improved health and well-being.
Female Clients
Could you be pregnant?
How many weeks
Do you have a history of miscarriage?
Do you suffer with PMT or Menstrual problems?
Are your periods

PainfulHeavyIrregularVery lightRegularI don't have periods
Date of last period if applicable

MonthDayYear
Date
Do you suffer with any menopausal problems?
If "Yes" to the above, please use this space to add any details:
Are you taking HRT or similar?

Client Declaration & Consent
The questions on this form have been asked to ensure my treatment is tailored to meet my needs and to highlight any contra-indications to treatment and/or essential oils. I confirm that I have not withheld any relevant information and the details given are correct to my knowledge.

I understand that my Therapist, Susie at Treasures of Nature, does not give medical diagnosis or treatment.

I understand all information is treated as confidential and will not be shared with any third party unless permission is given by myself, the client. All forms will be kept locked away and secure when not in use.

If any personal details or medical information changes, I will inform Susie accordingly.

I confirm that I have read and understood the Terms and Conditions and GDPR & Data Privacy Policy of Susie Taylor, trading as Treasures of Nature, and I consent to my personal data being collected and processed in accordance with UK GDPR.
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Date*

MonthDayYear
OPTIONAL: I consent to being contacted by email and/or SMS with appointment reminders, occasional updates or offers from Treasures of Nature. I understand I can withdraw my consent at any time by contacting Susie on 07790377645.
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Type a question
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General Health