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PKB Therapy

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01895 913 067
07960 060 088

info@pkbtherapy.com

3 Marlborough Parade, Uxbridge Road, Uxbridge, UB10 0LR

Opening Times

Monday

08.00 – 20.00

Tuesday

08.00 – 20.00

Wednesday

08.00 – 20.00

Thursday

08.00 – 20.00

Friday

08.00 – 20.00

Saturday

09.00 – 18.00

Sunday

09.00 – 12.00

Appointment Only

PKB Therapy Client Form

Personal Information
Name*
Phone Number (Day)
Phone Number (Evening)
Email
Date of Birth
DD slash MM slash YYYY
Primary Physician
Address
Street Address Address Line 2 City ZIP / Postal Code Country
Occupation
Employer
Emergency Contact Name
Emergency Contact Relation
Emergency Contact Phone
Where did you hear about us?
Medical Information
Are you taking any medications?
- Yes
- No
Please list Medication name and use
Are you currently pregnant?
- Yes
- No
How far along are you in your pregnancy
Are there any high risk factors in your pregnancy?
Do you suffer from chronic pain?
- Yes
- No
Please explain your chronic pain further
What makes your chronic pain better?
What makes your chronic pain worse?
Have you had any orthopaedic injuries?
- Yes
- No
Please list your orthopaedic injuries
You can use the + icon to add further injuries
Please tick any of the following that apply to you
- Cancer
- Headaches/Migraines
- Arthritis
- Diabetes
- Joint Replacement(s)
- High/Low Blood Pressure
- Neuropathy
- Fibromyalgia
- Stroke
- Heart Attack
- Kidney Dysfunction
- Blood Clots
- Numbness
- Sprains or Strains
Please explain any conditions you have marked above
Treatment Information
Have you had any professional treatment before?
- Yes
- No
What type of Treatment are you seeking?
Please specify what treatment you are seeking
What pressure do you prefer?
- Light
- Medium
- Deep
Do you have any allergies or sensitivities?
- Yes
- No
Please specify your allergies or sensitivities
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
- Yes
- No
Please explain the area you do not want massaged
What are your goals for this treatment session?
Please choose the side of the body you feel discomfort
- Left Side of Body
- Right Side of Body
- Front Side of Body
- Back Side of Body
Please explain your discomfort further e.g. lower back or upper leg
Agreement*
- I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Consent
I agree to the privacy policy
Client Signature
Signed Date: 21/06/2026

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01895 913 067

info@pkbtherapy.com

3 Marlborough Parade, Hillingdon, Uxbridge UB10 0LR (Appointment Only)

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