Client Information Form - Pavlina Holicova

Name *

First

Last

Contact Number

Emergency Contact Number

Email *

Address *

Occupation

Gender

Conditions and/or Symptoms:

Please indicate if you have any of the following

Allergies - Do you have any? Especially to oils?

(Sesame seed oil is used in Ayurvedic treatments)

Contagious / Infectious Diseases

Do you have any or have you been in contact with anyone with a contagious disease?

Medical Care / Treatment

Are you currently receiving any medical care or treatment such as chemotherapy, IVF, HRT etc?

Any other medical conditions

Have you ever had this treatment you have booked yourself for?

Reason for treatment

Client's Consent for Treatment

I have discussed the above with the therapist and I hereby consent to receive massages and treatments. I understand this treatment is provided at my request and I agree to undergo the said treatment at my own risk. I have been informed of the nature and purpose of the treatment. I understand that the above information will be kept confidential. I have read and understand the above Consent for Treatment.