Shopping Cart

Your Cart is Empty

Quantity:

Subtotal

Taxes

Shipping

Total

There was an error with PayPalClick here to try again

Thank you for your business!You should be receiving an order confirmation from Paypal shortly.Exit Shopping Cart

B Beautiful
Well-being

Home
Health Questionnaire
Covid Update
Contact Me
Location
Voucher & Payment
Cancellation Policy
Tai Chi Qigong
Workshops
Online sessions
Massage
Complimentary Therapies
Anti Ageing Treatments
Qualifications
After care Advice

Home
Health Questionnaire
Covid Update
Contact Me
Location
Voucher & Payment
Cancellation Policy
Tai Chi Qigong
Workshops
Online sessions
Massage
Complimentary Therapies
Anti Ageing Treatments
Qualifications
After care Advice

Health Questionnaire

Name*

Each section with a * next to the heading will need completing to be able to submit the form

Email Address*

Address*

Post Code*

Date of Birth

Contact Phone Number*

Emergency Contact*

Emergency Contact Number*

GP Surgery Name *

Current Medication list

If you are on a lot of medication you can bring me a repeat prescription list to keep in your records

Have you had Covid Vaccine/s*

When was your last Covid booster ?

Are you under Hospital Care at the moment?*

Consultant Name:

Hospital Address

Have you ever tested positive for Covid ?

If YES, what date ?

Tick if apply to you*

Do you have any of the following? Please tick the ones relevant to you. You can add information about a condition in the next section.

DiabetesEpilepsyOsteoporosisUndiagnosed PainTrapped or pinched nerveMetal plates or pinsEczema or PsoriasisVaricose veinsCurrent InjuriesAsthmaAcute RheumatismArthritisRecent operationsPacemakerUnder Active ThyroidOver Active ThyroidImplantsHigh Blood PressureLow Blood PressureHeart ConditionsBlood ConditionsCancerPoor CirculationMigrainesAllergiesLong covid diagnosisOtherNone

Any boxes you ticked please briefly explain

Medical consent for treatment*

Treatment consent

Please Read

I confirm that I have answered all questions to the best of my knowledge. I understand that if I have given a response which is untrue I may be placing myself at risk of an adverse reaction. I understand that the individual or company operating equipment or using of products will not be held liable for any adverse reaction that I may suffer as a direct or indirect result of my non – disclosure of any relevant facts or information requested by the questionnaire. I understand the information I have given is confidential and will not be released to a third party. I agree to notify Caroline of any changes from my initial consultation. I understand that any treatments I have will not be a substitute for conventional medicine. Under GDPR regulations, I consent to Caroline storing my information safely, knowing that my information will not be shared with anyone else.

Guidelines 2022

we are keeping safety policies in place to keep you and therapists as safe as possible. Please read

In order for clients to attend for treatments in person it is essential that you read the following information below:Please do not attend if you have symptoms that mean you may be contagious• Fill out any screening forms prior to coming for treatments so you get as much treatment time as possible• Turn up for your treatment at the allocated time. If you are early, please wait outside. You can text to say you have arrived.• Please remove any jewellery before hand and wear clothes easy to take off for massage treatments• Where possible come to appointments by yourself unless you need assistance or are under the age of 18.• Please pay for your treatment by bank transfer the day before. ( ask in advance for the relevant details) Card or cash payment can be taken on the day• Future bookings will be made by text/ email or phone to allow extra time for me to sanitise the room and equipment in between clients.• I will be offering alternative hours at my home treatment room in Birstall. The guidelines above still apply ( I have a toilet and basin next to the treatment room which is at the entrance of my home.• You will be sent a health check the day before your appointment, please fill this out ( its quick ) and send back same day.• Covid Vaccines and having had Covid are classed as medical changes and will need reporting to me so I can add this to you client records.

Cancellation Policy

As we now have to live and work with Covid, my cancellation policy has had to return. Please let me know asap if you cannot attend so I can offer your appointment to other clients. If you fail to attend or cancel within 24 hrs of your appointment time, a cancellation fee of up to the full amount will apply.

This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Thank you! Your message was sent successfully.

This is a confidential health questionnaire that must be filled out by every client before treatment or therapy commences. Please answer the questions as fully as possible.

It is important that you answer all questions the best you can to enable me to advise and assess your suitability for each therapy.

If you are unsure of any answers you can discuss with me by phone / text or email.

This information is for my use only and will not be given to a 3rd party . Your information will be stored under GDPR regulations

Just put your curser where you want to type and your keyboard should come up.

when finished press submit.

Home
Health Questionnaire
Covid Update
Contact Me
Location
Voucher & Payment
Cancellation Policy
Tai Chi Qigong
Workshops
Online sessions
Massage
Complimentary Therapies
Anti Ageing Treatments
Qualifications
After care Advice