Help restore balance to your body, mind and spirit

Consultation form

Consultation Form

Please complete the following details before your treatment. The form can also be completed in person. * denotes a mandatory field.

Please select where the treatment will take place

Your home

MyoMuscle Gym

NHS - Northumbria Healthcare / NHFM

NHS - Tees, Esk and Wear Valleys

Other

Please select your treatment(s)

Reiki

Reflexology

Both (2 sessions)

Select date of treatment (if known)

Please enter treatment time (if known)

Full name

Email (personal if possible)

Phone number (no spaces)

Please enter address only if I am visiting you at your home.

Address line 1

Address line 2

Town

County

Postcode

Medical history

Have you been hospitalised in the last 12 months? *

Yes

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

Yes

If you answered yes to any of the questions above, please give details below including any medication you are taking.

History or issues of any of the following?

Cardiovascular

Circulation

Digestive System

Joint / Skeletal

Lymphatic system

Nervous system

Reproduction system

Respiratory system

Please provide details below of any other history or issues?

Contra-indications - what you currenly have?

Contagious / Infectious diseases

DVT

Drugs or alcohoI

Fever

First trimester of pregnancy - until the end of the 13th week

Please provide details below any other contra-indications?

Please tick to show that you declare that the information you've provided is accurate & complete.

Please tick to show you agree with the following. "I declare that the information that I have given is true and correct and, as far as I am aware, I can undertake treatment without any adverse effects. I understand that Reflexology and Reiki are not a substitute for medical advice and/or treatment. It is my choice to receive Reflexology treatments as a form of therapy. I understand that at any time I feel pain or discomfort during the session, I will immediately inform the practitioner so they can adjust the pressure and or treatment. We are compliant with General Data Protection Regulations (GDPR) and are committed to ensuring the security and protection of all personal information."

Thank you for submitting.

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