Personal Details

Name

First Name

Last Name

Contact Number

Nearest Town

I don't require your full address but it's helpful to know where you're located

Email Address

Date of Birth

YYYY

Occupation

Emergency Contact Name

First Name

Last Name

Emergency Contact Number

Name of Doctor

Surgery Name

General Health and Lifestyle

Do you exercise regularly?

Are you currently taking any medication?

Are you on a special diet?

How would you describe your stress levels?

High

Medium

Low

How would you describe your energy level

High

Medium

Low

Do you smoke?

If yes, what is the average you smoke per day?

Do you drink alcohol?

If yes, how many units do you consume per week?

How would you describe your sleep pattern?

What do you do for relaxation?

Do you suffer from any allergies?

Please list allergens and possible reactions

Have you had a massage treatment before?

Reson for your treatment

Conditions and/or symptoms

Please give further details on any of the above conditions

Female Clients

Are you pregnant?

If you are pregnant, how many weeks along are you, and have you experienced any complications?

Are you currently breast feeding?

Date of your last period

YYYY

Have you had an IUD fitted in the past 12 weeks?

If you have a gift voucher to use please add the code here

I declare the information that i have given is true and correct and that as far as I’m aware, I can undertake treatment at Meant to Bee Therapies without any adverse effects. I understand that reflexology is not a substitute for medical advice and/or treatment

GDPR Compliance

Your personal data will be stored and be accessible by Meant to Bee Therapies - Jade Adair Your information will not be shared to any third party companies. We will only contact you with regards to Meant to Bee Therapies and associated matters and will never send spam to you. Medical Malpractice: Your details will be kept on record for 3 years once you have recieved your last treatment with Jade Adair Record Keeping Your consultation forms are kept on file on a password protected computer and paper files are kept in a locked filing cabinet at my home address. Your files are not viewed or accessible by anyone other than Jade Adair, unless consent is given by yourself to share with other therapists. Medical Information Required The medical & emotional questions are required so that Jade Adair can provide a Holistic Treatment for you.

COVID-19 Policy

I understand that I am required to wash my hands when I arrive for my appointment. I must inform my therapist (Jade) if I am feeling unwell and/or experiencing any symptoms of Coronavirus and must cancel my appointment. Details of the Meant to Bee COVID-19 Policy can be found here https://www.meanttobeetherapies.com/covid19-policy

Thank you for submitting your information. I look forward to meeting you at your treatment.

If you haven't yet scheduled your treatment please contact Jade on 07764 748393 or email Jade@MeantToBeeTherapies.com to arrange.

Many thanks

Jade

Bodywork Consultation Form

Bodywork Consultation Form