Your Name: (required)

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Gender:
MaleFemale

Treatment Type: (required)
ReflexologyFacial ReflexologyZone Face LiftIndian Head MassageReikiHolistic Massage

Reason For Treatment & any additional info (required)

Conditions requiring medical consent or a disclaimer form to be signed:
ThrombosisPhlebitisHypertensionHypotensionHeart conditionsAny condition already being treated by a GP or complimentary practitionerMedical oedemaOsteoporosisArthritisNervous/ psychotic conditionsEpilepsyRecent OperationsDiabetesAsthmaMultiple sclerosisParkinsons diseaseMotor neurone diseaseOther disfunction of the nervous systemTrapped/ Pinched nerveInflamed nerveCancerSpastic conditionsKidney infectionsAcute rheumatismPostural deformitiesCervical spondylitisUndiagnosed painWhiplashSlipped discOn prescribed medication

Conditions that might restrict treatment:
FeverContagious/ Infectious diseasesUnder the influence of alcohol or recreational drugsDiarrhoea & vomitingPregnancySkin diseasesLocalised swellingInflammationVaricose veinsCutsBruisesAbrasionsScar tissuesSunburnHaematomaRecent fracturesSlipped disc

I confirm that the above information is true to the best of my knowledge. I understand that if I have any of the above conditions or health concerns it is my responsibility to consult with my GP before treatment and obtain consent. Otherwise, I confirm that I am willing to proceed without consulting my GP and hereby indemnify Anna Vermond against any adverse reaction sustained as a result of treatment:

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