Name *

First Name

Last Name

CURRENT HEALTH CONSIDERATIONS *

Please do let me know if you have any of the below conditions/considerations.

= No known health concern =

High blood pressure or other heart condition

Post-operative

Diabetes Type 1

Diabetes Type 2

Cancer

Respiratory condition

Suppressed immune system

BMI over 39

Difficulties with mobility (please detail in the final box below, so that we can address any accessibility issues.)

Pregnant

A condition not listed (please detail in the final text box below)

Do you struggle with your physical mobility (walking up or down stairs for example)?

I will need to know about any problems with your physical mobility so that I can ensure that you can access the treatment room. Please detail anything that you feel I may need to know in the final box on this form.

Yes, I do have additional mobility requirements (I have outlined this below)

No physical considerations required

Client Disclaimer *

Please read the following carefully and only click that you agree if you are in full agreement: • I understand that the services offered today are not a substitute for medical care. • I will consult my GP or Consultant before my treatment if I have any condition that requires approval for bodywork treatments. It is your responsibility and not that of the therapist to consult your GP or Consultant. • I will notify you of all known relevant medical conditions and injuries. • I will inform you of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. • If I experience pain or discomfort during the session, I will immediately inform you so that pressure/techniques can be adjusted to my level of comfort. I will therefore not hold you responsible for any pain or discomfort that I may experience during or after my session that could have been avoided through communication and adapting to your needs and preferences.

I agree

I am unsure and would prefer to discuss this in person