Medical Form

Thank you for booking a treatment with Amaya Healing! So that we may offer you the best service, please could you complete and submit the medical form below, at least 48 hours prior to your appointment. All information will be kept PRIVATE and CONFIDENTIAL

Full name:

Please provide details of any surgery/operations you've had in the last 5 years? Please provide details of any implants / pins / pacemaker / piercings etc you have? Please give details of any cosmetic procedures including botox, fillers etc) which you have had WITHIN THE LAST TWO WEEKS?

Do you suffer from a low immune system? Are you prone to infections and frequent coughs, colds, sore throats? How good would you say your digestive system is?

Do you experience Muscular/Skeletal problems? Aches and pains, back problems or headaches?

Do you have problems with circulation? Heart, blood pressure, cold hands and feet?

Do you have Gynaecological issues? Are you pregnant or trying to conceive?

Do you suffer with any of the following? Epilepsy, migrane, tension, stress. depression, anxiety, asthma, shortness of breath, wheezing, cough. Or anything not included in the list?

What is your skin type? Dry, oil, combination, sensitive, dehydrated. Do you suffer/have you suffered from: Dermatitus, acne, eczema, rosacea, psoriasis, allergies, hay fever, skin cancer?

Is there anything else that your therapist should be aware of before proceeding with your treatment?

I certify that the information provided is true and accurate to the best of my knowledge and that relevant consent has been obtained from my GP. I understand that the Therapist will not be liable for any incidentals that may occur as a result of any omissions or undisclosed information. By submitting this form I consent to treatment.

Thanks for submitting!