General consultation form
Please fill out the following health declaration form in order to book a treatment with me. Submissions has to be done prior your booking. Thank you for taking your time to do that. I will check and get in touch, if there are any concerns. Looking forward to pampering you soon.
I agree to inform immediately, if my body temperature is getting higher than 37°C, develop a cough or loose my sense of taste and smell in the last 24 hrs prior the treatment.
Heart Condition
Yes
No
If YES, elaborate more
High or low blood pressure
Yes
No
If YES, elaborate more
Diabetes
Yes
No
If YES, elaborate more
Cancer
Yes
No
If YES, elaborate more
Loss of skin sensation
Yes
No
If YES, elaborate more
Bruises
Yes
No
If YES, elaborate more
Pregnancy
Yes
No
If YES, elaborate more
Epilepsy
Yes
No
If YES, elaborate more
Recent scars or surgeries (under 6 months)
Yes
No
If YES, elaborate more
Skin disorders
Yes
No
If YES, elaborate more
Medication
Yes
No
If YES, elaborate more
During hemotherapy or radiotherapy
Yes
No
If YES, elaborate more
Allergies
Yes
No
If YES, elaborate more
Phlebitis
Yes
No
If YES, elaborate more
Medical Odema
Yes
No
If YES, elaborate more
First Name
Last Name
Email
Phone Number
Address
Please leave instructions for parking. I am caring heavy equipment, so free immediate parking to the property is required.
Please upload a doctor's notes, if you have a medical condition and require adapting on your treatments
Select a File
I agree to the terms & conditions and I confirm that the information given in this form is true
Date
Your Signature
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