Kirsty Elwood BodyMind Consultation

Name*

First NameLast Name

Date of Birth*

Address*

Address

Address line 2

TownCounty

Post Code

Mobile Number *

Area CodePhone Number

Email*

example@example.com

Dr Name & Address*

Surgery Address

Address Line 2

Town

Are you currently on any Medication? Could you please state the name of the medication, what its treating and how long you have been on them please:*

Illness/Surgery/Accidents: Have you had any recent illness, surgery or been involved in any accidents over the last year?*

Sleeping Patterns: Are you sleeping well at the moment?:*

Female: Could you be pregnant? If so, how is this pregnancy and have you had any problems in the past?*

Female: Are your periods regular?*

Do you..*

	Yes	No	Quantity (Per day)
Smoke
Drink Coffee
Drink Alcohol
Drink Water

Do you suffer with any problems relating to the following:*

Please list any other current health conditions not mentioned above*

What is your stress level right now?*

LowAverageSomewhat StressedVery Stressed

At time of completing this form what is your health status?*

Signature*

Please be aware of recent 2021 location and price changes:

Reflexology - £45i

Reiki - £30

Foot Reading - £35

Reflexology and Foot Reading combined - £70 (£10 discount)

New Location: I am now based from BeYOUtifi in Donaghadee every Fri & Sat. Please contact me for London prices and information

9 Kylestone Road, Donaghadee, BT21 0PS

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive the holistic treatment or foot reading.

2) I understand that therapeutic massage is not a substitute for traditional medical
treatment or medications.
3) I understand that the therapist does not claim to heal, cure, prescribe or diagnose illnesses or injuries,
4) I have clearance from my Doctor where necessary to receive the treatment / therapy I am booking for.
5) I fully understand the risks/healing crisis associated with reflexology, reki,massage therapy, include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Kirsty Elwood BodyMind from all liability concerning these injuries that may occur during the treatment session as I am aware of the risks.
6) I understand the importance of informing my therapist of all medical
conditions and medications I am taking, and to let the therapist know
about any changes to these at any ongoing appointments. I understand that there may be additional risks based on my physical condition.
7) I understand that it is my responsibility to inform my therapist of any
discomfort I may feel during the session so he/she may adjust the treatment
accordingly.
8) I understand that I or the therapist may terminate the session at any
time.

9)Photos of your treatments may be taken to aid in record keeping, and to be used with your permission on social media to help advertise the services available

10) I am aware that our appointments are subject to late cancellation due to guidlines in place with CV19 regulations.
11) I have been given a chance to ask questions about the session
and my questions have been answered.

HEALTH RECORD

Terms and Conditions