Consultation Form

First name

Last name

Email

Phone

Occupation

Medical Information ( Any health conditions please make clear ) - Please circle

Is there anything else we should know regarding your health?

Are you taking any medication or homeopathic substances?

Are there any area that you’d like us to concentrate for this massage treatment?

Treatment note :

Therapist name ( if know ) :

Your permission : I hereby consent to the use of my personal data (including any sensitive personal data) for the purpose of my treatment and any future treatment. I confirm that treatment is at my own risk without limiting or affecting any statutory rights I may have. Healing Point does not treat any medical condition. Healing Point will not be responsible for any pain, injury, reaction, or medical problem following a massage treatment. Personal data will be held by Healing Point.

Date and time

:

Signature