Form

Consultation form

Client Pregnancy Treatment Consultation Form. The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Treatment time:

60 minutes90 minutes
Week of pregnancy:
Occupation:
Current Medication (inc vitamins):
What is the objective of your visit (eg: relaxation, specific condition / pain)? *
Your General Health
Do you suffer from any of the following pregnancy related conditions?*

BackacheMorning SicknessHeartburnHeadaches / MigraineDepression / Anxiety / Panic AttacksDiarrhoea / Constipation / IBSSciaticaAnemiaOedema (Swelling)High Blood PressureLow Blood PressureAbdominal PainVaginal BleedingSensory Loss (numbness)Urination IssuesLeg Cramps / PainClotting Issues (suspected deep vein thrombosis)Any other conditions not listed here (please go into detail below)
Please detail any other conditions:
Stress Levels at Work

HighMediumLow
Stress Levels at Home

HighMediumLow
Exercise / Hobbies?
Have you experienced any of these health conditions in the past or present?

Hormone Imbalance (eg PCOS / irregular cycle)CancerHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisordersFever BlistersHerpesFrequent Cold SoresHIV / AIDSLupusDepression / AnxietyHepatitisHeadaches / MigranesCovid-19OtherNone
If you checked yes to any of these please provide further information. If not mark N/A
Any known allergies (eg: aspirin, latex, nuts, essential oils)?

YesNo
Are you a smoker?

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)

YesNo
Do you drink alcohol?

YesNo
Have you ever experienced claustrophobia?

YesNo
Is there any other information you would like to make your therapist aware of? If yes, please give details:
Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 50%. Suspected Covid-19 and severe pregnancy related issues are exceptions to this rule, but please do let me know asap
I understand the reservation and cancellation policies at Under Your Skin and consent to my credit card on file being charged if I fail to give the required notice.
CLIENT DECLARATION: I declare that the information I have given is correct and as far as I am aware I can undertake a treatment with out any adverse effects. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and I am willing to proceed. I understand that complimentary therapies do not substitute medical treatment. If I experience any discomfort during the treatment I will inform the therapist immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release the therapy from liability and assume full responsibility thereof. I understand that my therapist may require me to obtain permission from my doctor before my appointment.

By checking this box I understand and accept this statement.
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Consultation form

Your General Health