Marion Jenkins Therapies Dibden Purlieu - Organic treatments to make you feel amazing

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Client Pre-MLD Treatment Consultation Form

Marion Jenkins Therapies

MLD Massage treatment Intake Form

First Name

Last Name

Email *

Phone *

Address *

City *

County *

Postal code *

Date of birth *

Occupation *

Doctors Name & address *

Marital Status *

Children: *

Current Height *

Current Weight *

For insurance purposes; Our treatment bed holds a maximum of 18st/114.3kg

How did you hear about us?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

Please list Injuries or surgeries:

Have you ever received professional skin care treatments or massage?

Yes
NO
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Any problems during Prior treatments & massages

Medical History ( Please tick all that apply)

Acne

Allergies

Anaemia

Arthritis

Asthma

Athletes Foot

Back problems

Blood Pressure H/L

Boils

Bruises

Burns

Cancer

Cellulite

Chilblains

Circulation

Cold Sores

Conjunctivitis

Constipation

Contact Lenses

Cramp

Depression

Diabetes

Diarrhoea

Epilepsy

False Teeth

Fractures

Hayfever

Headaches

Migraine

Heart Problems

Hernias

Hip Problem

Indigestion

Insomnia

Irritable Bowel

Kidney Disorder

Oedema

Phlebitis

Pregnancy

Prosthesis

Sinusitis

Skin Conditions

Thrombosis

Ulcers

Varicose Veins

Verucca

Weight Disorder

Menstrual Problems

Nerve Damage

Sensitive Skin

Any Other Relevant Information

Do You smoke

Light

Social

Moderate

Do you drink alcohol

Light

Social

Moderate

Precautions following an MLD Massage Treatment:

1) Drink plenty of water following a massage treatment, recommended eight glasses

2) A little oil in the hair is unavoidable, please advise your therapist if you have hair extensions

Disclaimer:

I confirm that to the best of my knowledge, the answers I have given above are correct, and I have not withheld any information that may be relevant to my treatment. I agree that I am happy to receive the treatment outlined to me

Client Signature

Clear

Date of signature & submission

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