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Treatment Waiver

Please fill out the following form

First Name

Last Name

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Do you have, or have ever had the following? (please tick or circle on te relevant medical details and give details where applicable

Circulatory disorder

Heart condition

High or low blood pressure

Thrombosis

Epilepsy

Diabetes

Recent Haemorrhage

Recent operation / fracture / sprain

Nut allergy

Wheat allergy or intolerance

Allergies Dermatitis Eczema Psoriasis

Terminal Conditions (e.g. cancer)

Arthritis

Asthma / Breathing difficulties

Skin disorder

Sciatica

None of the above

Please feel free to let us know of any back, shoulder, neck or aches and pains that you would like us to work on

Are you currently taking any medication including herbal remedies

Are you currently under GP or Hospital care

Female Clients only

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Telephone: 07368 369586

St Ives Barns Spa

St Ives Road

CO5 7QD

© 2021 St Ives Barns. Created by SIB designs

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