Client Pre-treatment Form

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This confidential form is necessary for us to ensure the treatment we provide is suitable for you and allows us to tailor the treatment to your specific needs. We may want to discuss some of your answers below with you during treatment to help us better understand your condition or how we may adapt the treatment for you. The details below are completely confidential and we will not share your details below with anyone else without your consent.

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Adresse e-mail *

Covid19 Policy

If you are experiencing any of the following please contact us to POSTPONE your appointment for at least TWO WEEKS after you are better:

PERSISTANT COUGH
TEMPERATURE
LOSS OF TASTE AND/OR SMELL

If you have been in contact with anyone who has had the above symptoms or has been confirmed with Covid19, please postpone your appointment for 2 weeks.
There are no penalties for postponement of appointments.

We advise clients to wear a mask for their appointment and to come alone. Please arrive on time and no more than 5 minutes early. Please bring your own water.

For further information on how we are keeping you safe please see our website- www.restsalon.com

I have read and understood the Covid19 policy outlined above and will adhere to the conditions above for my appointment. *

I agree

Name *

Date of birth *

YYYY

Mobile phone number *

Doctors name and contact details *

Primary reason for treatment

Pain relief and/or rehab

Relaxation

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Health History- Please tick any conditions you are currently suffering from or have a history of.

Any skin conditions that may be affected by the treatment, eg eczema, psoriasis, or contagious skin conditions such as Ring worm, Impetigo

Thrombosis or varicose veins

Any heart conditions

Diabetes or any condition affecting skin sensitivity

Undergoing treatment for a long term illness eg Cancer

Arthritis- Osteo or Rheumatoid

degenerative muscular conditions

IBS or digestive disorder

Pregnant- Please note we cannot treat you before 12 weeks

Recovering from surgery

Any undiagnosed pain- sport injuries, limb injuries

Any undiagnosed inflamation or Oedema

Reduced movement

Taking medication, other than contraception.

Anxiety or depression

Insomnia or interrupted sleep

Allergies- Including NUT allergies as some of our products can contain nuts however we can adapt the products used, where necessary.

If you ticked any of the boxes above, please use this space to expand futher- details of any medication, areas of discomfort or pain, details of any injuries or surgery, details of any restrictions of movement.

Please add below any requirements you have for the treatment including pressure preference and areas to focus on.

In completing this form above, I agree to my treatment and have disclosed any medical information that may be affected. *

I agree

Many thanks for completing this form. If you have any qustions you can contact us on info@restsalon.com.
We look forward to seeing you for your appointment.

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