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m assage therapy

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Consultation Form

PREGNANCY MASSAGE

Please fill out the following form in order to see if the pregnancy massage is suitable

First Name

Email

Doctors Name

Have you been hospitalized in the last 12 months? *

No

Yes

is your pregnancy considered high risk? *

No

Yes

Last Name

Date of Birth

Doctor phone number

Are you suffering from a medical condition, illness, or injury?

No

Yes

any areas of pain?

No

Yes

Please select any that apply:

Undiagnosed Lump or awaiting results *

Heart Conditions/ Thrombosis/ Phlebitis / Heart attack*

Acute Inflammation*

Cancer/ Melanoma in the last 5 years *

Tubercolosis*

Malignant melanomas*

Diabetes

Are you pregnant

Are you menstruating

Diarrhoea or Vomiting

High Blood pressure

Low Blood pressure

Fibromyalgia

Kidney issues

Asthma

Epilepsy

Oedema **** Is it a result of Heart and Kidney Disease

Hyperactive Thyroid

Arthritis

Any other condition being treated by GP or other complementary practitioner?

Removal of spleen

Implants

Joint Replacements

Liver issues

Heart disease

Neuropathy

If you answered yes to any question, please elaborate

I declare that the info I’ve provided is accurate & complete and that I am responsible for checking with my doctor if the session is suitable for me

I will inform my therapist if anything changes before my session

I accept terms & conditionsView terms and conditions

I agree to photos taken for marketing purposes (no face)Photography consent form

Your Signature

Thanks for submitting!

McLoughlin Scar Tissue Release Approved Practitioner

Privacy Policy

A professional member of CThA and CHNC . CThA and CHNC does not endorse or approve any products or services

Soothicity is a trading name of Protea Therapies Ltd Registered in England. Company No: 11752572.

The Soothicity name and the Soothicity "Rising Sun Lotus" are Registered Trademarks and may only be used with permission from Protea Therapies Ltd

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