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Indian Head Massage Treatment Form

First name*

Last name*

Email*

Phone*

Address*

Conditions and/ or symptoms (contraindications to the treatment)

Swelling/oedema

Mental Health Condition

Phlebitis

Unstable blood pressure

Heart disorders

History of thrombosis/embolism

Epilepsy

Infectious diseases

Skin disorders

Recent scar tissue

Haemorrhage

Varicose Veins

Recently had any operations?

Have you ever had or do have cancer?

Back problems

Recent fractures or sprains

Currently suffering from a fever, diarrhoea or vomiting?

Diabetes

Osteporosis

Arthritis

Allergies

Asthmatic conditions

Is a doctor/ complementary practitioner treating you for any condition?

If you have ticked any of the options above please explain further below:

Do you have any medically diagnosed conditions? If so please give details

Please give details of any medication you are taking

Please give details of any allergies you have

Female clients only: If you are pregnant, how many weeks are you?

Is there anything else that you would like me to know?

PRIVACY POLICY

GDPR (implemented by DPA2018 in the UK) brought in new legal protection for personal information from May 2018. This tells you what personal information I hold and why, and what your rights are.

The privacy policy can be found here.

By checking this box you are confirming that you have read the privacy policy at the above web address and understand that I will hold and use your personal information, using it in order to provide you with the best possible treatment options and advice in line with the statements mentioned in the policy.

CLIENT DECLARATION

By submitting this form I declare that the information I have given is true and correct. I am not aware of an underlying condition that would prevent me from undertaking treatments or may cause adverse effects to the treatment described.

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data privacy

This form collects your name, telephone number and email address along with your message so that I can communicate with you and provide you with assistance. Please check the Privacy Policy to see how I protect and manage your submitted data.

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open

Mon 9.30-3pm

Tues 9.30-8pm

Wed 9.30-8pm

Thurs 9.30-3pm

Friday 9.30-3pm

info@clarericcireflexology.co.uk

07843 240 409

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