NinaTCM

Client Intake & Consent Form

Your details

First name *

Last name *

First name

Last name

Email *

Phone Number *

Phone Number

Date of birth *

Date of birth

Health & preferences

Please acknowledging NinaTCM has ZERO TOLERANT policy against any kind of disrespectful language and behaviour.

Please reschedule if you have any contagious symptoms.

Please list any medical conditions, major surgeries, current medications and allergies. If none, write “None”. *

Please list any medical conditions, major surgeries, current medications and allergies. If none, write “None”.

What would you like help with at this appointment? *

What would you like help with at this appointment?

Relaxation and stress relief

Muscle or joint pain

General health and wellbeing through Chinese medicine

Not sure — I’d like Nina’s guidance

Treatment consent

Do you give consent to REMEDIAL MASSAGE THERAPY? *

Do you give consent to REMEDIAL MASSAGE THERAPY?

Do you give consent to CUPPING THERAPY ? ( May leave bruise like mark on you for days but not painful) *

Do you give consent to CUPPING THERAPY ? ( May leave bruise like mark on you for days but not painful)

Do you give consent to NEEDLING THERAPY? ( Use Acupuncture needles to stimulate trigger points in muscles, can feel like a sting ) *

Do you give consent to NEEDLING THERAPY? ( Use Acupuncture needles to stimulate trigger points in muscles, can feel like a sting )

Do you give consent to AROMATHERAPY? ( Essential Oil Blend Therapy ) *

Do you give consent to AROMATHERAPY? ( Essential Oil Blend Therapy )

Yes

Yes — I have allergies (please specify)

Media consent & signature

Do you consent to photos or videos of your treatment being used on NinaTCM’s social media? Your face will not be shown. Choosing No will not affect your treatment. *

Do you consent to photos or videos of your treatment being used on NinaTCM’s social media? Your face will not be shown. Choosing No will not affect your treatment.

Your Signature *

Your Signature

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