Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you active? *

Yes

No

Your last doctors visit

Just a rough date if unsure

MM

DD

YYYY

Contraindications requiring medical permission – in circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to the treatment.

Medical Odema

Skin Cancer

Nervous / Psychotic Conditions

Slipped Disc

Epilepsy

Undiagnosed Pain

Recent Facial operations affecting the area

Pregnancy

Diabetes

prescribed Medication (please list below)

Contraindications That Restrict Treatment

Fever

Abrasions

Contagious or infectious diseases

Scare tissue (2 years for major operation and 6 months for small scar)

Under the influence of recreational drugs or alcohol

Sunburn

Hormonal implants

Diarrhoea and vomiting

Recent fractures (min 3 months)

Eczema

Sinusitis

Undiagnosed lumps and bumps

Neuralgia

Localised swelling

Migraine/Headache

Inflammation

Hypersensitive Skin

Cuts

Bruises

Botox/dermal fillers (1 week following treatment)

Thyroid

Digestive problems

Do you eat regular meals or on the go? *

I eat my 3 meals a day

I eat when I can and/or on the go

I (the client) *

Approve

Date *

MM

DD

YYYY

I have not been diagnosed or cared for someone diagnosed with Covid-19 in the past two weeks. *

Yes

No

I have not shown any symptoms of Covid-19 or come into contact with anyone displaying these systems in the past two weeks. *

Yes

No

I do not have a cough, fever, chills, shortness of breath or loss of taste or smell. *

Yes

No

If I begin to show symptoms of covid-19 within the two weeks I will contact Collective Therapies. *

I understand

I will follow the procedures outlined in the correspondence provided to keep myself, my Therapist those around me safe. *

I understand

Name *

First Name

Last Name

Date *

MM

DD

YYYY