Trusted Bodywork client information
Confidential client information for deep tissue and holistic massage
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Email *
First name *
Last name *
Address line 1 *
Address line 2
Address line 3
Town *
Postcode *
Telephone no *
Emergency contact name *
Emergency phone *
Agreed date of 1st massage treatment *
MM
/
DD
/
YYYY
Date of birth *
MM
/
DD
/
YYYY
Referral
GP phone no *
GP name *
GP address *
Can I contact your GP and share any information you have given me? *
Tell me the nature of any accessibility issues you have that I need to account for in either the Zoom consultation or the treatment
Do you want to be added to the Trusted Bodywork newsletter list to be notified about news, articles, events and offers? Your email address will never be passed to any third-party and, at your request (using the email opt-out function) you will be unsubscribed.
Excluding the above, do you authorise Trusted Bodywork to retain all information you submit for the purposes of supporting your treatment only? It will not be shared with any 3rd party without your explicit permission (e.g. Your G. P.). At your request, either verbally or in writing, Trusted Bodywork will remove all data about you but be aware that I cannot then continue to treat you. *
Required
How did you find out about Trusted Bodywork? *
A copy of your responses will be emailed to the address you provided.
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