BOOK YOUR APPOINTMENT

I am available with restricted timings on weekdays and all day on weekends.

Please call or email to book your appointment or use the online form and I will get back to you.

jikku2006@gmail.com 01384437111

First Name *

Last Name *

Email *

Phone Number *

Service Required *

Select a date *

CONSULTATION

Sex *

Date of Birth *

Contraindications (any potential reason to avoid treatment)

Select any injury that has been diagnosed and treatment has been recommended by a medical practitioner.

Select...

Additional Contraindications

Select any additional conditions that may affect treatment.

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Personal Problems

Select any personal problems that may affect treatment.

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List any antibiotics / medication you are taking:

Please list any allergies including any skin allergies that could be caused by massage oil, cream or wax.

Do you exercise? How many times a week?

Are you left or right-handed? *

Notes

DISCLAIMER

Please read the following and tick the appropriate box, by ticking the box you are confirming you are in full agreement with the statements contents.

I confirm that I have understood the treatment that I am going to receive. I also confirm that I am willing to proceed without confirmation from my own G.P or Consultant.

I consent to full treatment by Renew Body Therapy which can include any of the following: Joint adjustment or manipulation or mobilisation to the joints of my spine (neck and back), pelvis and extremities (shoulder, upper limbs and lower limbs), Cupping Therapy, IASTM Therapy, The use of a hand held Massage Gun and Full body Sports Massage Therapy. This consent applies to all my present and future treatments at Renew Body Therapy.

Please tick this box if you are happy for any photographic or video content pre, during or post treatment to be shared and used for promotional purposes.

You should note that if the therapist is unable to explain to you the contraindications or is unsure of anything that may apply to a specific condition then they should not treat you without asking you to consult with your GP or Consultant. It is your responsibility and not that of the therapist to consult your GP or Consultant.

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