Client Consultation & Consent Form

The information requested below is required to assist us in ensuring that your treatment is tailored to you, and there are no contraindications to you receiving any of the treatments you may be booking in for.  All information is treated in the strictest of confidence and in accordance with our privacy policy. Thank you for your time in completing the form in full.

Consultation & Consent Form

Please complete all sections of the form as fully as possible. Thank you.

NEXT OF KIN - we require these details for your health & safety and in case of any emergency.

MEDICAL INFORMATION - if any of the following do not apply, please write 'not applicable'. Thank you

Do you currently have any of the following conditions? If yes, please tick all that apply:















Are you, or could you be, pregnant?



Have you had an accident in the last 12 months?



Have you ever had any major operations?



Do you smoke?



Do you drink alcohol?



Do you engage in taking recreational drugs?



Do you have problems sleeping?




Do you eat a balanced healthy diet?



Do you consume drinks with Caffeine in them?



Do you take regular exercise?



Declaration & Consent (Please read this section carefully)

I declare that I have not withheld information from the practitioner at Tranquil Mind UK. I understand that Reiki and other complementary therapies are not a substitute for medical or psychological diagnosis and treatment, and also understand it is recommended I see a registered Doctor or health care professional for diagnosis and treatment of any physical and/or psychological conditions if I have not done so already. I, the undersigned, have completed the consultation and consent form as fully and accurately as I can and believe the details to be correct to the best of my knowledge. I consent to having treatment with the practitioner at Tranquil Mind UK and I release the practitioner from any negligent misrepresentation that may be contained in this form. I have read, understood and agree to the general policies and codes of practice, including the privacy policy, of Tranquil Mind UK.

Are you signing this form for somebody under the age of 16? By signing this form on their behalf, you are also declaring that you have parental responsibility for the client named above, as detailed in the general policies and codes of practice of Tranquil Mind UK.




 

Copyright 2018