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"Natural Lift" Pre-treatment Consultation Form

"Natural Lift" Holistic Facial Massage

Birthday
Day
Month
Year
How did you hear about ReikiEma?

Medical Details

Have you received Massage Therapy or any other Complementary or Holistic Therapies before?

Past Complementary Therapies/Massage

Other therapies

Are you pregnant or trying to get pregnant?
Yes - trying
Yes - pregnant for less than 3 months
Yes - pregnant for more than 3 months
No
Please tick to indicate which of the following apply to you (as many as are relevant).

Disclaimer / Client Statement


For my records, I need to confirm that you have read, understood and answered all of the previous questions. If there is anything you do not understand, or wish to ask about, please ask me now (before signing this statement).

 

Otherwise, please read the following statement, and sign below to show that you agree.

 

To the best of my knowledge, the information I have given in this form is true, and I have not withheld any information concerning my health.

I will keep Ema Melanaphy updated on my health, should there be any changes to the answers already given.

I understand there is a possibility I may experience some minor reactions as my body adjusts to the treatment.

 

I understand that the therapist does not diagnose illness, disease or any other physical or mental condition. I understand that this treatment is not a substitute for medical examination, diagnosis or treatment. While I recognise that all due care will be taken by the therapist, I am aware that my participation in the treatment is voluntary.

 

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Ema Melanaphy is a qualified professional Reiki Practitioner CNHC Registrant (the UK Government's voluntary regulator for Complementary Therapists), a Reiki Master Teacher member of the UK Reiki Federation, and is accredited by the Reiki Federation as a professional Animal Reiki Practitioner. Ema has been a professional Reiki practitioner since January 2020, and is a qualified practitioner of Reiki, Animal Reiki, Pregnancy Massage, "Natural Lift" Rejuvenation Facial Massage, Holistic Acupressure, and also a Student Practitioner of Zen Shiatsu. Ema is a Certified professional Therapeutic Meditation Teacher, and a certified Independent Reiki Master Teacher of Usui Shiki Ryoho and Usui Reiki Ryoho, since 2021.

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Complementary and Natural Healthcare Council logo - links to CNHC website listing for Ema Melanaphy. Text reads "CNHC Registered
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"professional (TM) standards Authority accredited register" with the psa logo, in the bottom half of the box.
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