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Client Consultation Form

Personal information

First Name *

Last Name *

Email *

Telephone *

Date of Birth *

Treatment details

Are you here for?

Preference of therapist

No Preference Female Therapist Male Therapist

Have you had massage or holistic treatments before?

Yes No

Medical history

Please answer honestly so our therapists can provide safe and suitable treatment.

Condition

Yes

No

Any condition being treated by GP or other therapist

Yes No

Inflamed nerve

Yes No

Skin conditions / eczema / psoriasis / rash

Yes No

Recent operation within 6 months

Yes No

Abrasions / broken skin / scar tissue / bruising

Yes No

Diabetes

Yes No

Rheumatism / Arthritis / Osteoporosis

Yes No

Undiagnosed pain

Yes No

Slipped disc

Yes No

Cancer

Yes No

Heart condition

Yes No

Pregnant

Yes No

Currently taking medication

Yes No

If yes to any condition, please give details

Additional questions

Areas to focus on

Areas to avoid

Pressure preference

Consent & signature

We collect this information to provide safe and suitable beauty and holistic treatments. Health information is treated as confidential and is only accessed by authorised staff for treatment and client care purposes.

I consent to Himalayan Beauty collecting and processing my health information for safe treatment consultation.
I confirm the details provided are accurate to the best of my knowledge.
I would like to hear about latest offers and promotions.

Signature

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Beauty & Holistic Sanctuary in the heart of Dublin.

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+353 (01) 224 7018
+353 087 902 7141
info@himalayanbeauty.com
11 St Stephen's Green
Dublin 2, Ireland

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