Client’s Consultation Form

Client's Consultation Form

Name *

First

Last

Phone *

Date / Time *

Date

Time

Profession

Email *

Age Group *

• Under 20
• 20-30
• 30-40
• 40-50
• 50-60
• 60+

Lifestyle *

• Active
• Sedentary

Preferred Gender of Therapist *

• Male
• Female
• Either

Emergency Contacts *Next of KinPhysicianEmployer or Embassy

Phone *

Medical History

• Asthma
• Hepatitis
• Diabetes
• Epilepsy
• High Blood Pressure

Covid-19 Status *

• Positive
• Negative
• Unknown

Specify incase of any other

Allergies

Contraindications that may restrict treatment

• Fever
• Pregnancy
• Skin Diseases
• Inflammation
• Cuts
• Varicose Veins
• Bruises
• Abrasions
• Sun Burns

Layout

Services Requested *

Amount Paid *

Client's Temperature *

Client's Signature *

Therapists Name *

Therapists Comments *

Therapists Signature *

Submit