This consultation form is for clients who are attending with me for the first time.

Please complete at least 24 hours before your booking.

By making me aware of any limitations, conditions or allergies, I can adjust your session accordingly - completing online in advance of your booking helps to ensure that you get the most out of the time at your appointment.

This information is private and confidential. Please see terms for information.

Initial Consultation Form

Please fill out the following form.

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date of birth

Day

Month

Year

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please specify and supply additional information.

Do you have any allergies or intolerances?

No

Yes

If you answered yes to the question above, please specify and supply additional information.

Are there any herbs, essential oils or plant extracts that you are unable to have contact with due to any medication you may be taking or allergies you may have?

No

Yes

If you answered yes to the question above, please specify and supply additional information.

Have you been diagnosed with any of the following in the last 10 years?

Cancer/Melanoma/Lymphoma/Parkinson’s Disease /Alzheimer’s Disease (please specify below)

History of Embolism/Haemorrhage/Stroke /Paralysis/Blood disorders (please specify below)

Undiagnosed Lumps/Recent Surgery (please specify below)

Heart Condition/Pacemaker/Heart Surgery (please specify below)

Cerebral Palsy/Multiple Sclerosis/Spinal Cord Injury (please specify below)

Metal implants/Prosthetics/ Infectious disease or Skin Condition (please specify below)

Epilepsy/Other Seizure Disorder (please specify below)

Diabetes Type 1/Diabetes Type 2 (please specify below)

None of the above

If you selected any of the conditions above, please specify and supply additional information.

Please detail any supplements, herbal, homeopathic or unprescribed medication you are taking

What is your blood pressure?

High

Low

Normal

I don't know

Signature

I declare that the information I’ve provided is accurate and complete. By booking, I agree to the Terms and Conditions and I understand it is my responsibility to be aware of these. I have completed as accurately as I can and that all conditions and medications, including alternative remedies and supplements, have been disclosed to the practitioner.

I agree that the practitioner may use additional and/or supportive therapeutic methods she professionally considers appropriate to ensure the best possible holistic treatment. I understand that all modalities offered at VOLVA are not replacements for medical care. Any recommendations are for educational purposes only.

I fully understand that my health is my own responsibility, to research any recommendations and check with my primary health care provider before proceeding. I understand that the treatments do not claim to diagnose and/or cure any condition. I release the practitioner from any misrepresentation.

I would like to subscribe to the VOLVA newsletter and updates

YULE CLOSING 21st dec - 4th jan

Initial Consultation Form

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