About You

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Format: 0000-000-0000.

Address

Street Address

Street Address Line 2

City

Postcode

What do you do for a living?

What do you do with your spare time?

Next of Kin

First NameLast Name

Next of Kin Contact Telephone

Format: 0000-000-0000.

My Covid vaccination status is

My next vaccination is booked for

Date

If you are unvaccinated then you hereby agree to wear a mask throughout the treatment in order to prevent transmission, as far as is possible. Extra cleaning and sanitisation procedures for therapist and equipment will also be necessary and so there will be a £5 charge added to the cost of treatment to cover this.

I confirm that I do NOT have any of the following symptoms at the present time and that I will inform the practitioner if any of the below develop between the completion of this form and the booked appointment

I agree that I will take a lateral flow test on the day the appointment is booked and inform the practitioner of a positive result. The practitioner will also complete a lateral flow test on the day of treatment. Treatment will not take place if you are not prepared to agree to this condition.

Have you been in contact with anyone who has tested positive for Covid within the last 14 days?

Are you allergic to latex gloves or any cleaning products?

Please give details of any allergies to cleaning products here

Are you considered a higher risk individual?

If yes, please give details here

GP Name

First NameLast Name

GP Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Please tell me about any medical conditions here:

Do you take any medication?

Medication details, if relevant

Please tell me about any surgery you've had, recent or otherwise

Please tell me about any injuries, recent or otherwise

Are you allergic to anything?

Please give details of any allergies here

Women, is there any chance you might be pregnant?

What is your due date?

Date

Have you had any complications so far in your pregnancy?

If yes, please give details here:

I confirm that I have provided true and accurate information to the best of my knowledge. I accept that Essential Massage and Soft Tissue Therapy ('Essential') will use the information here only as a baseline for treatment and that any omission which affects my treatment is not the fault of Essential.

Essential undertakes to keep all information provided here confidential in line with the requirements of GDPR (2018). Essential further undertakes to only release this information to other practitioners with your express written permission. Please be aware that the law currently requires that medical records are kept for 7 years post-treatment for adults and until the age of 21 for anyone treated before they turned 18. All records will be securely destroyed after the relevant time period has elapsed.

Essential will not contact you without permission, as detailed below. Ticking the box confirms that you agree to these Terms and Conditions and are happy to proceed with treatment on this basis.

Acceptance of terms and conditions

Thank you for your time in completing this form - I look forward to meeting you soon!

About You

Covid Screening

Medical Details

If you are pregnant, please fill out the section below: