Before your visit

Your consultation form

A few confidential details so your treatment is safe and tailored to you. It takes about three minutes. Please complete it before your appointment.

Website

Your details

Name *

Date of birth

Email *

Phone *

Address

Occupation

Full or part time?

Full time Part time

Next of kin

Your appointment

Treatment

Appointment date

Your doctor

GP name

GP phone

Clinic address

May we contact your GP if needed?

Yes No

Health & safety

This keeps your treatment safe. Please answer honestly.

Have you had Botox in the past 3 weeks? (facial reflexology / ZFL clients)

Yes No

Diagnosed medical conditions and medication details

Any side effects to medication

Caution check — tick anything that applies to you

Acute undiagnosed pain Cardiovascular condition Allergies Varicose veins / phlebitis Diabetes Imminent medical tests or procedures Epilepsy Recent surgeries Osteoporosis Injury or condition linked to the area worked

If you ticked any above, please give details

Lifestyle

How are you feeling in yourself at the moment?

Energy levels

Lifestyle & wellbeing

Tell me anything you feel may be relevant to your treatment.

Anything else I should know before we begin?

Consent

Confidential. Your visit and the information in this form are treated with the strictest confidence and managed under the appropriate GDPR guidelines. The Nurture Room holds it only to provide your treatment safely and keep your records. It is never sold or shared for marketing, and is kept only as long as needed for your care and any legal requirement. You can ask to see, correct or delete your information, or withdraw your consent, at any time, or complain to the Irish Data Protection Commission (dataprotection.ie).

I confirm the information above is accurate and complete to the best of my knowledge. * I give my explicit consent for The Nurture Room to process the health information in this form to provide my treatment safely. I understand I can withdraw this consent at any time. *

Signature

Sign with your finger or mouse in the box below.

Type your full name *

Sign here

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Thank you

Your consultation form has been sent securely to The Nurture Room. There is nothing else to do. I look forward to seeing you.

The Nurture Room · Tralee, Co. Kerry · your details are kept private and secure · Privacy