Emergency Contact Name

Emergency Contact Number

Are you currently under the care of a GP or consultant?

Yes No

If yes, please provide details:

Have you received medical clearance for massage if required?

Yes No Not Applicable

Contraindications Checklist

Please tick (✓) any condition that applies to you now or within the last 12 months.

General Health

Skin Conditions

Cardiovascular

Musculoskeletal

Neurological

Respiratory

Digestive & Abdominal

Endocrine

Diabetes Thyroid disorder None

Cancer & Lymphatic

Pregnancy

Blood Disorders

Infectious Diseases

Allergies

Recent Medical Procedures

Other Medical condition not listed above

Are you currently taking any medication?

Yes No

Please specify:

Do you smoke?

Yes No

Do you consume alcohol?

Yes No

Average glasses/units per week:

How many litres of water do you drink daily?

Exercise frequency:

Have you had professional massage therapy before?

Yes No

If yes, what type?

When was your last massage?

Today’s Consultation

What is your main reason for today’s visit?

What areas would you like treated?

What pressure do you prefer?

Light Medium Firm Deep

Current pain level (0–10)

Please describe any pain, discomfort or restricted movement:

What are your goals for treatment?

Consent to Treatment

I understand that massage therapy is intended to promote relaxation, improve circulation, reduce muscular tension and enhance general wellbeing.

I understand that massage therapy is not a substitute for medical examination, diagnosis or treatment by a medical professional.

I understand that I should inform my therapist immediately if I experience any discomfort during treatment.

Please Tick the Following

I affirm that the information I have provided above is true and accurate to the best of my knowledge. I acknowledge my responsibility to inform my therapist of any changes in my medical condition as indicated in this document. It is especially important to update this information before any future appointments, since new contraindications for treatment may arise. I understand that any package of massage therapy I purchase is non-refundable and non-transferable. I agree to adhere to the scheduled appointment times. If I need to cancel or reschedule, I will provide at least 24 hours’ notice; otherwise, or if I fail to attend, I will be charged the full session fee.

Photography & Video Consent

From time to time, photographs and/or videos may be taken for clinical purposes, such as documenting posture, range of movement, treatment progress, or outcomes. Separate permission is requested if images are to be used for marketing or educational purposes.

Clinical Records

I consent to photographs and/or videos being taken and securely stored as part of my confidential clinical records.

Marketing & Social Media

I understand that any images or videos used for marketing will only be used with my explicit permission.

Consent

I consent to photographs and/or videos of me being used on the Naturopath Medical Ltd. website, social media platforms, printed marketing materials, and other promotional content.

I understand that I may withdraw my marketing consent at any time by contacting Naturopath Medical Ltd. Withdrawal of consent will not affect any material already published prior to the withdrawal request where removal is not reasonably practicable.

GDPR & Privacy Consent

At Naturopath Medical Ltd., we are committed to protecting your personal information in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.

Your personal and medical information will be used solely for the purpose of providing safe and effective treatment, maintaining accurate clinical records, communicating with you regarding your appointments, and complying with our legal and professional obligations. Your information will be stored securely and will not be shared with third parties without your consent unless required by law or where necessary to protect your vital interests.

Clinical records are retained in accordance with applicable legal and professional record-keeping requirements.

Please tick to confirm:

I have read and understood the Privacy Notice and consent to Naturopath Medical Ltd. collecting, storing and processing my personal and medical information for the purposes of providing treatment and managing my care, in accordance with UK GDPR and the Data Protection Act 2018.

By signing this form I accept the Terms & Conditions of Naturopath Medical Ltd. printed below.

Naturopath Medical Ltd. Terms & Conditions

1. All treatments, courses, and packages must be paid in full either at the time of booking or at the conclusion of your first appointment. 2. To reschedule or cancel an appointment, you must provide at least 24 hours’ notice.

3. Cancellations made less than 24 hours before your appointment—or missed appointments—will result in forfeiture of that session (if part of a course or package) or the full session fee being charged.

4. If you arrive late, only the remaining appointment time will be provided. Arrivals more than 20 minutes after the scheduled start time will result in cancellation of the appointment without refund.

Confirmation

I confirm that I have read and agree to the above Terms & Conditions.

Hello, sign in

NATUROPATH MEDICAL LTD

Massage Therapy Client Consultation & Medical Questionnaire

Medical History

Contraindications Checklist

Medication

Lifestyle

Today’s Consultation

Consent to Treatment

Photography & Video Consent

GDPR & Privacy Consent

Naturopath Medical Ltd. Terms & Conditions

Client Declaration