Anything disclosed on this form is confidential, will be
used for medical purposes only and not shared with
anyone else. By completing this form, you are giving
consent to treatment. I may from time to time send you
a promotional email or newsletter, if you would prefer
not to receive this, please tick the box here.
Client Consultation Form
Client information
Date
Email address
Client Name
Mobile phone
DOB
Address with Postcode
Occupation/Business type
Your Sports Activities: type and frequency
Doctors Name and Address
Service type, e.g. Sports
Massage/Yoga/Rehab/Rugby Team
Special Requirements or Sensitivities
Medication currently taken; prescribed
drugs/herbal/steroids/ formulas/other.
Are you currently receiving treatment from
another health specialist or medical
practitioner? If yes, what for?
Previous significant injuries, long term
musculoskeletal pain, operations, & approx. date.
Health Conditions; asthma, epilepsy, heart
problems, coeliac, cancer, etc, etc, etc.
Current injuries, pain or problems.
Any Allergies, Mental Health Problems, Learning
Difficulties?
I, the client detailed above, understand why I am
having, and give consent to treatment.
Peony Cottage, 21 Affpuddle, DT2 7HH
………………………………………………………
07967 135896
www.dorchesterbodyworks.com
Peony Cottage, 21 Affpuddle, DT2 7HH
07967 135896
www.dorchesterbodyworks.com