Ellior Client Intake Form
  • Client Intake Form

    All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose. 
  • greatbodywork

    Claire Feldkamp MA, MTI (dip), CAMR, RYT280
  • Date of birth*
     - -
  • Format: (00000) 000000.
  • Format: (00000) 000000.
  • Tell me about your life and your body

  • Do you smoke?
  • Do you drink alcohol?
  • Are you Hypermobile?
  • Do you suffer from any of the following
  • Respiratory
  • Cardiovascular
  • Autoimmune
  • Infections
  • Women
  • Massage Policies:

    All information collected is 100% confidential. Written authorisation is required from you to release any information to any other healthcare provider.

    • Please turn off your cell phone during the session
    • You can reschedule your session upto 24 hours before it starts
    • No refunds are given if you fail to show up for your session
    • Please do not come to a session when you have a virus, which includes the common cold
    • You will be fully clothed at all times
    • You agree to inform me of any changes to your medical history

    Client Agreement:

    Bodywork is a two-way process, so you will never be asked or forced to move to a place where you feel uncomfortable. Whilst we work together, I will ask you to provide verbal feedback on pressure so it can be adjusted if needed. This is your time, and your knowledge of your body is far superior to mine, so please tell me if anything needs adjusting for you.

    I (the client) understand that the services offered to me are not a substitute for medical care. I understand that Claire Feldkamp is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

    Client data is used for the purposes of providing treatment and to comply with insurance and professional memberships. Client records are stored for 8 years, after which time they are deleted. You can request to see your data at any time by emailing me at hallo@clairefeldkamp.co.uk

    By my electronic signature below, I agree to the massage policy and client agreement above. 

  • Date
     - -
  • Should be Empty: