Brief Consultation Form - Jayne Sarah Therapies

Name*

This is just a quick check to make sure you're well enough to be massaged and are free of Covid symptoms. Please complete it up to 48 hours before each therapy session. If there are no changes since I last saw you, only complete the minimum info required 🙂 Thanks!

First Last

Email*

Phone*

Agreement:*

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.

Cancellation Policy:*

You agree to give a minimum of 24 hours’ notice should you need to cancel a therapy session and understand that you will be charged the full price of the session if you do not give 24 hours’ notice (with the exception of experiencing symptoms of a contagious or infectious illness, in which case you agree to cancel with immediate effect and understand there will be no charge for this).

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

Medical Information Gathering

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 pregnant?

Do you have a nut allergy?

Do you have low or high blood pressure?

If yes, please provide details.

Please tell me about any recent surgery or broken bones you have had (in the past 5 years):

Please tell me about any medical conditions you have:

If you are taking any medication, please provide details:

Lifestyle Questions:

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?

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

Health Statement:

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:

Quick Pre-Massage Consultation Form with Covid Questions

Medical Information Gathering

Lifestyle Questions:

Health Statement:

Thank you for completing this form up to 48 hours before your therapy session. I look forward to seeing you soon!

Qualifications & Accreditations