Client Consultation

Client Consultation
Name*

First NameLast Name
Title
Address*

Street Address

Street Address Line 2

City

Post Code
DOB*
Phone Number*

Area CodePhone Number
Email
example@example.com
GP Address
GP Telephone*
Emergency Contact*

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 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 have read and understand the Terms and Conditions.
Terms and Conditions

If you need to cancel or reschedule your appointment, please contact Susie at Treasures of Nature on 07790377645 at the earliest opportunity.
- If you are unwell or have had any recent sickness and may still be contagious, please do not attend your appointment but contact me at the earliest convenience.
- Do not attend if you have high levels of alcohol or recently taken recreational drugs, to avoid any possible adverse reaction with essential oils and/or your treatment.
- Any vaccination, please allow a week either side of your appointment.
- Reflexology appointments: Should you be troubled with athletes foot, please make sure this has been treated and cleared before your appointment. Any verrucae or fungal nail, please do treat and cover the area yourself before your treatment. Reflexology can be done on the hands if it is not possible to treat the feet.
- Aromatherapy/Massage appointments: Please avoid using any lotions or perfumes before your appointment to avoid any reaction with essential oils and carrier oils. Loose comfortable clothing is recommended.
  Cancellation and Rescheduling Fees
Cancellation Fees

72 hours plus – no cancellation/reschedule fee.

Within 48 hours – 50% payment of the treatment price.

Within 24 hours – 100% payment of the treatment price.

Missed appointments

Any missed appointments without notification will incur 100% payment of the treatment price.

Arriving late

If you are running late, please do try and safely let me know. Each session is booked for a specific time slot and appointment time or payment cannot be changed accordingly.
Signature

Clear
Date*

MonthDayYear
Should be Empty:

Client Consultation

General Health

Female Clients

Medical History

Mental Well-being & Lifestyle

Your hopes and wishes...

Client Consent