CONSULTATION FORMS

If this is your first visit with us, please fill out the consultation form relevant to your booked session by clicking the buttons below. All information provided will be strictly private and confidential.

Massage or Cupping Form

Acupuncture Form

massageform

acupuncture-consultation-form

New Client Consultation Form (Acupuncture)

First Name

Last Name

Phone

Birthday

DOES ANY OF THESE CONDITIONS APPLY TO YOU?

Allergies

Taking prescribed Medications

Joint replacement or implant/ Recent surgery

High or Low blood pressure

Bruising or Open Wounds

Could you be Pregnant? If so, please specify how many weeks

MAIN COMPLAINT

What is the main reason for treatment today?

Where is it located? How does it feel like?

How often does it manifest & What triggers it?

How did it occur the first time & How long has it been going on?

Have you been diagnosed and/or are you receiving any treatments for your ailment?

DIGESTION AND BOWELS MOVEMENT

Do you experience any pain/bloating/rumbling after eating?

Do you experience any burping/acid reflux after eating?

How many times do you empty your bowels per day?

Are your stools hard/loose/soft and shaped?

If you answered yes to any question, please elaborate

DIET

What do you usually eat at breakfast, lunch & dinner?

At what time do you usually have dinner?

How many cups of water do you drink per day?

Do you regularly drink alcohol? If so, how many units per week?

Do you usually eat cold or raw food? And drink cold drinks?

SLEEP

How many times do you wake up at the night and why? Do you stay awake?

What time do you go to sleep? Do you fall asleep easily?

Do you regularly have nightmares or vivid dreams?

Do you feel refreshed when you wake up?

PAIN

Do you have headaches? If so, in what part of the head, sides/front/back/inner?

Do you have any joints pain or in your limbs or chest? If so, please specify.

Do you have any back pain? If so, upper/middle/lower back?

OTHER

Do you usually have palpitations?

Do you usually sweat out of blue?

How is your energy level? (0 low – 10 high)

How is your stress level? (0 low – 10 high)

What is the main cause of your stress?

What is your most consistent emotional state?

MENSTRUAL CYCLE (if applies)

Are you in menopause?

How long is your cycle? Is it regular?

How many days does your period last?

What is the colour of your menstrual blood? (Bright red/dark red/light red)

Do you have any clots or spotting between periods?

Do you have any physical or emotional discomfort prior your period?

Do you have any physical or emotional discomfort at ovulation?

Do you use pads/tampons/sanitary pants?

Do you use any contraceptive? If so, which one and how long for?

Do you grind your teeth at night/during the day?

Do you smoke? If so how many per day?

PLEASE READ CAREFULLY

1) I, the undersigned, declare that the information I have given is true to the best of my knowledge and I have no withheld any information concerning my health. I understand there is a possibility I may develop some minor reactions as my body adjusts to treatment.

2) I understand, and I am informed that in the practice of Massage Therapy there are some slight risks to treatment, including some minor reactions such as muscle and joint soreness, as the body adjusts to treatment. but also muscle strains, joint sprains, fractures, disc injuries, nerve injuries, stroke and stroke-like episodes and possible worsening of underlying conditions. I understand that results are not guaranteed, I do not expect the therapist, to be able to anticipate and explain all risks and complications, and I wish to rely on the therapist to exercise judgment during the course of the treatment, which she feels at the time, based upon the facts then known, is in my best interests.

The information provided on this form will be treated with the stricter confidence and safety.

3) Certain examinations or procedures (such as Acupuncture and Cupping), which form a normal part of therapy may be invasive in nature and may involve sensitive parts of the body. To ensure there are no misunderstandings between practitioner and patient, the practitioner will give a full explanation of any procedures prior to treatment commencing.

I understand that my medical records will be handled and stored according to the Data Protection Act (1998).

I will answer all questions relating to my medical history and lifestyle correctly and to the best of my ability.

I understand I will have a clear explanation of the treatment and possible side effects, including superficial bleeding and bruising from areas particularly rich in blood.

I understand I can request to stop treatment during procedure.

I will make sure that I am satisfied with the safety and hygiene COVID measures put in place.

I consent to having a course treatment.

I DON'T WANT TO RECEIVE OCCASIONAL NEWS & OFFERS

I AGREE THAT I AM PROVIDING ACCURATE HEALTH INFORMATION.

Select a date

Your Signature

Thanks for submitting!

COVID-19 HEALTH & SAFETY PROTOCOLS

In response to the rising concerns regarding COVID-19, I would like to take this opportunity to explain our new health and safety protocols. These have been established in accordance to the government requirements, WHO, Public Health England and our professional association guidance, in order to ensure your health, safety and wellbeing at all times.

OUR HYGIENE PROTOCOL

We will ensure a 10min gap between each client to have enough time to thoroughly clean and disinfect everything in the treatment room. This will include all touch points such as the table, door handle, card reader etc. We will sanitise the massage couch after each use, especially around the face cradle with antibacterial liquids and wipes.

We won’t be using a massage cover at this time, but we will cover the bed with couch roll, disposable face cradle covers and wipeable pillows as an additional precaution.

PPE: We will wear a face mask and visor at all times. As a standard procedure we will also be wearing gloves and an apron which will be changed for each client. If you prefer to receive your treatment without gloves, this is still possible (as it is not a compulsory safety requirement, just please let your therapist know.

You are not required to wear a mask, even tough we would suggest you to do so.

CLIENTS COVID-19 GUIDELINES

1. If you are feeling unwell or have a temperature or showing any COVID-19 symptoms, you must let us know prior to your appointment and we will discuss about the cancellation/rescheduling.

2. Digital thermometers are installed at the entrance of the clinics (we will be only operating at the Light centre in Monument and in Moorgate at the moment). You will be responsible for taking your temperature on arrival. Anyone showing a temperature higher than 37.8 degrees C will be required to leave site immediately.

3. On arrival, please make your way to the reception area to wait for your Therapist to collect you, but only enter the reception a few minutes before your therapy time slot. If there is no reception staff member on shift, please text us on 075 9537 8108 to be let into the centre and wait outside until entry is permitted.

4. Even tough it is not compulsory, we strongly advise you to wear a mask inside the common areas of the centre and please respect the government advised social distancing guidelines with regards to any staff, other clients, practitioners or anyone else in the building except within the treatment room.

5. Once inside the centre please use the hand sanitiser provided on entry (available inside front door)

6. PAYMENT: We still accept payment both by card and cash, even tough payment ideally should be made prior to the appointment via Bacs or card (following a link we will provide upon receiving your booking request) to avoid touching card machines or money.

7. CANCELLATION POLICY:

In this difficult time, we are afraid we won’t be able to allow any exceptions and last minute cancellations as the centres where we operate have also changed their cancellation policy and we can’t be as flexible as before.

We now have a No-Show and Late Cancellation Protection in place, therefore, in order to secure your slot we now need you to confirm your appointment through the Fresha app. After your booking request, you will receive an email asking to add your card details to your booking but please be reassured that YOU WON’T BE CHARGED AT THIS TIME. Our new cancellation policy allows you to cancel for free up to 24 hours ahead, otherwise you will be charged 50% of the service price for late cancellation or 100% for not showing up.

If you are feeling unwell, please do not come to your appointment and let us know as soon as possible.

8. Please also bring your own water as we are not using any glassware at the moment.

LIGHT CENTRE HEALTH & SAFETY PROTOCOLS

Both the Light centre in Monument and Moorgate have also implemented their health and safety protocols to ensure all common areas are regularly disinfected and social distancing is maintained at all times.

COVID-19 CONTRACTION EMERGENCY POLICY

We will keep a detailed list of all clients we see and their contact details and we will have to provide this information to the Light centre in the event that any person who has been in the Centre (while you were on site at that time) contracts COVID-19.