Pre-Massage Consultation Form with GDPR and Covid Questions

Name*

First Last

By reading and signing this document you are agreeing to permit our therapist to give you a massage. You are also agreeing to Jayne Sarah Therapies’ terms and conditions. This document will be held on file and kept securely and confidentially in line with GDPR.

DOB

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email*

Phone*

What is the reason for your treatment? I.e. Relaxation, Tense Shoulders, Achy Legs etc.*

Are you pregnant?*

Yes - less than 12 weeks pregnant
Yes - more than 12 weeks pregnant
No
N/A

Do you have a nut allergy?*

Yes
No

Are you a Vegan?

I will use vegan massage oil for you.

Yes
No

Do you have low or high blood pressure?*

If yes, please provide details.

Have you had any recent surgery or broken bones (in the past 5 years?)*

If yes, please provide details.

Do you have any medical conditions?*

If yes, please provide details. Some medical conditions may require you to receive permission from your GP before a treatment can be conducted. This is for your own safety. Please discuss any issues with your therapist before the treatment begins.

Are you taking any medication?*

If yes, please provide details.

What is your occupation?*

Do you do a lot of driving or cycling?

Is your lifestyle active or sedentary? If active, which activities and how frequently?*

Do you drink plenty of water?*

Do you drink much alcohol?

Do you smoke?

Is there anything else you would like to inform your therapist of today?

How did you hear about Jayne Sarah Therapies?*

Word of Mouth
Google
Facebook
CNHC / Embody / NCH / AfSFH Website
Referral Voucher
Flyer/Leaflet
LinkedIn
Hypnotherapy Directory
Other

If a person told you about us, please name them:

How may I respond to your enquiries?

Text
Email
Phone Call

How may I contact you with appointment reminders, rearrangements and cancellations?

Text
Email
Phone Call

Would you like me to email you with general information about Jayne Sarah Therapies, including special offers?

Yes

Would you like me to email you vouchers?

Yes

Vouchers include Gift vouchers, Birthday vouchers, Christmas vouchers, Thank you vouchers, Feedback vouchers and others.

Please can I email you a Feedback Form after your first session?

Yes

How can I contact you with aftercare advice, such as stretches and relevant information?

Text
Email

Health Declaration

Please confirm the following statements. If you cannot agree to all of them, please detail below.

I understand that I must not attend an appointment with Jayne Sarah Therapies if I have any infectious or contagious illness
I have not tested positive for COVID-19 in the last 14 days
I do not live with anyone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days.
To my knowledge, I have not been in contact with anyone with symptoms of Covid-19, such as fever, a new persistent cough or loss of taste or smell, in the last 14 days.
If either I, or someone I have been in contact with, tests positive for Covid-19 I will inform you.
I understand that by attending future sessions, I agree to all of the above on an ongoing basis and will cancel any future sessions should my health be compromised beforehand.

If you are unable to confirm any of the health statements above, please provide further information here:

AGREEMENT FOR TREATMENT*

I understand that I must give at least 24 hours notice to cancel treatments with Jayne Sarah Therapies, otherwise I will be charged a full price cancellation fee. (The only exception to this is a sudden onset of a contagious or infectious illness.)
I am happy to go ahead with the massage treatment. I understand that on the day of my treatment I will be advised of the effects of massage and how it may affect any of the conditions I have listed above.

Pre-Massage Consultation Form with GDPR Permissions and Health Questions

Qualifications & Accreditations