New Client Consultation Form

Consultation Form

The following information will be used to help plan a safe and effective treatment. If you can't answer anything please dont' worry we will go through it. All information will remain private and confidential.
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

City

Country
Phone Number

PrefixPhone Number
E-mail
Occupation
Emergency Contact Name & Mobile
Have you had holistic or skincare treatments before?
Are you currently attending a GP/complimentary therapist for any condition/treatment?
GP / Therapist Name & Address and details of condition / treatment
Current Medication (incl vitamins):
How did you hear about me?
If Referral, please list name
What benefits would you like to get from your treatment
Your General Health
Have you experienced any of these health conditions in the past or present?

Other
If you checked yes to any of these please provide further information. If not mark N/A
Stress Levels at Home
Stress Levels at Work
Do you do any regular exercise?
Any known allergies (eg: aspirin, latex, nuts, essential oils)?
*If Yes, please give details:
Are you / could you be pregnant
Are you a smoker?
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
Do you drink alcohol
What is your daily water intake (glasses / litres)
Have you ever experienced claustrophobia?
Are there any other information you would like to make your therapist aware of? If yes, please give details:
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee of 50% may be applied. No shows will be charged 100% off the booked treatment cost.
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.
I, Lindsay Ferry t/a New Pathways Skincare & Holistic Therapies will occasionally contact clients to follow up on a session. I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please tick the box if you DO NOT want New Pathways to contact you:
Signature
Thank you for taking the time to complete this form - I look forward to seeing you soon.

Lindsay
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Consultation Form

Your General Health