Client Consultation & Consent Form

Client Consultation & Consent Form

Holistic Wellness by Irina Lopes, UK. Please complete this mobile-friendly consultation and consent form before your appointment.
Personal Details
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
GP Surgery
Appointment Details
Which treatment are you booked for?
Is this your first visit?
What is your main reason for today's appointment?
If “Other” is selected, show a short text box.
Medication
Are you currently taking any medication?
Do you currently have, or have you previously been diagnosed with, any of the following?
If “Other” is selected
Medication details (names, doses, and relevant notes)
Allergies
Do you have any allergies?
If yes, please provide allergy names and reaction details
Current Symptoms
Current symptoms
Pain scale

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Lifestyle
Daily water intake
Exercise frequency
Smoking
Alcohol consumption
Treatment-Specific Screening: Lymphatic Drainage
Is this treatment for:
Type of surgery
Date of surgery

MonthDayYear
Date
Country where surgery was performed
Has your surgeon cleared you for treatment?
Are you wearing a compression garment?
Current symptoms
Treatment-Specific Screening: Foot Recovery Reset
Do you have diabetes?
Do you have fungal nails?
Do you have verrucas?
Do you have athlete's foot?
Do you have ingrown toenails?
Do you have any open wounds on your feet?
Do you have reduced sensation in your feet?
Treatment-Specific Screening: Warm Stone Therapy
Do you have heat sensitivity?
Do you have reduced sensation?
Do you have diabetes?
Have you had any recent burns?
Consent
I confirm the information I have provided is true and accurate.
I understand massage therapy is a complementary therapy and is not a substitute for medical care.
I agree to inform my therapist of any changes to my health before future appointments.
I understand treatment may be modified or refused if it is not safe to proceed.
I consent to massage therapy.
I consent to hot stone therapy where appropriate.
I consent to cupping therapy where appropriate.
I consent to the use of professional massage oils, creams, urea cream and other skincare products where appropriate.
I understand that I may stop treatment at any time.
I understand that at least 24 hours' notice is required to cancel or reschedule my appointment and that late cancellations or missed appointments may be subject to a charge.
Photography and GDPR
May we take clinical progress photographs for treatment records?
GDPR consent
Signature
Electronic Signature
Date

MonthDayYear
Date
Should be Empty:

Client Consultation & Consent Form

Personal Details

Appointment Details

Medication

Allergies

Current Symptoms

Lifestyle

Treatment-Specific Screening: Lymphatic Drainage

Treatment-Specific Screening: Foot Recovery Reset

Treatment-Specific Screening: Warm Stone Therapy

Consent

Photography and GDPR

Signature