Holistic Therapies Medical History and Consent Form | Beauty Forms Portal

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Medical History and Consent Form

Client Details

Name: *

Date of Birth: *

Contact Number: *

Email: *

Address: *

ZIP/Postal Code: *

Emergency Contact

Emergency Contact Name: *

Emergency Contact Phone: *

Relationship to you: *

Medical History

Are you currently taking any medication or supplements? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Do you have any medical conditions? *

Please list: *

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Consent

I have, following consultation, consideration and discussion, agreed to undergo this therapy.

I am fully aware that the services I wish to receive are those of a holistic nature and do not serve as a substitute for professional medical advice, examination, diagnosis or treatment.

I have had the procedure explained to me and understand the nature of the treatment.

I fully understand this treatment is not a substitute for medical treatment and it may take several sessions before I notice any benefit. This will depend on my lifestyle, ongoing medication and general health.

I understand that if I have failed to give enough relevant information the outcome of any therapy/treatment/class could be adversely affected and my health and well-being may be put at risk.

I understand the therapist/practitioner/trainer does not claim to cure or to diagnose any medical condition in the same way as a doctor/physician. Their opinion is that of a holistic, complementary and alternative therapist and their professional opinions, advice, examinations and recommendations do NOT constitute the medical advice of a doctor/physician.

Client Signature: *

Tap or click on the signature above to sign

Appointment Guidance

If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.

COVID-19 Symptoms:

a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
a loss or change to your sense of smell or taste
shortness of breath
feeling tired or exhausted
an aching body
a headache
a sore throat
a blocked or runny nose
loss of appetite
diarrhoea
feeling sick or being sick

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