Home/test-form test-form Booking form Calming Space - Indian Head Massage Therapy TREATMENT DATE & TIME NAME OF THERAPIST * Tracy Cotter Date * Time 121234567891011 : 0030 AMPM CLIENT DETAILS * First name First name Surname Surname Address * Address Address Address Town or City Town or City Country Country Postcode Postcode Date of Birth * Email Email * Mobile Phone Number * Landline Phone Number DOCTORS DETAILS - GP Name & Address Doctors Name Surgery Name Surgery Address Just enter the locality if you don't know the full address GENERAL HEALTH General heath and immunity? * Good Average Poor Stress Levels? * High Medium Low Energy Levels? * High Medium Low Do you find time for relaxation and hobbies? * Often Sometimes Never CONDITIONS THAT AFFECT TREATMENT Please select any of the condition that apply to you. Conditions that prevent treatment * Temperature or fever? Any infectious condition and or disease. Skin infection anywhere, including scalp infection. (nits, lice, etc.) Serious heart condition or circulatory disorder. Recent stroke, haemorrhage or blood clot. Recent unhealed injury operation or surgery. Pregnancy, first trimester, or possible suspected pregnancy. Under the influence of drugs or alcohol. Diarrhoea and or vomiting. Cancer (active) and receiving chemotherapy or radiotherapy. NONE OF THE ABOVE PREVENTATIVE CONDITIONS APPLY Conditions that can hinder treatment * Cardiovascular conditions such as thrombosis, phlebitis. Hypertension, Hypotension. Minor heart conditions, haemophilia and medical oedema. Recent head injury. Or neck injury, including whiplash. Fractures or sprains?, legs, arms, hands or feet. Recent operations or surgery? Epilepsy, asthma or diabetes. Osteoporosis, spondylitis, rheumatoid or osteo-arthritis Undiagnosed lumps, bumps or swellings. (Even if not painful.) Recent severe undiagnosed headaches or migraine. Paranoia, psychosis or schizophrenia? Very high or very low blood pressure. Cancer (in remission) if discomfort or side effects remain. Cerebral palsy, multiple sclerosis. Parkinsonism. Pregnancy (second or third trimester), and HBP, dizziness and nausea. Trapped, pinched or inflamed nerve. Kidney infection. Slipped or herniated disc. Minor wounds, bruises, cuts, or abrasions. Minor wounds, bruises, cuts or abrasions. Recent or still sensitive scar tissue. Varicose veins, localised, swelling or inflammation. Sunburn, hypersensitive, cut, bruised or sensitive skin. Menstruation (if uncomfortable or sensitive abdomem). Severe allergies or any allergies. Any condition that might affect, or be affected by, treatment. NONE OF THE ABOVE HINDERING CONDITIONS APPLY CLIENT DECLARATION & CONSENT Please confirm each of the following * The Information I have given is correct. As far as I am aware I can receive therapy without adverse effects. I have been informed about Contra-conditions and am happy to proceed with therapy. I understand that Indian Head massage is a complementary therapy, not a substitute for medical for treatment. Signature * Clear GDPR Agreement * I consent to having this website store my submitted information in relation to the therapy being received. GDPR is the General Data & Privacy Regulations If you are human, leave this field blank. Submit Calm
