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Section Four — Consultation

A confidential medical questionnaire.

This information is used only by your practitioner to ensure your treatment is safe and tailored. It is stored securely under UK GDPR and never shared. The form takes about four minutes.

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✓ Treatment ✓ Date & Time ✓ Payment Selected 4 Consultation

Section OneYour Details

Section TwoEmergency Contact

Section ThreeGeneral Health

Are you currently pregnant or trying to conceive? Many lymphatic and sculpting techniques are contraindicated in pregnancy.

Have you given birth in the last 6 months, or are you currently breastfeeding? We adapt pressure and technique for postpartum guests.

Are you currently taking any prescription medication? Including hormonal medication, antibiotics, immunosuppressants.

Section FourCardiovascular & Renal

Have you been diagnosed with any heart condition? Including arrhythmia, angina, valvular disease, or recent cardiac events.

Do you have high or low blood pressure that is not currently well-controlled?

Do you have, or have you had, kidney disease or impaired renal function? Lymphatic drainage temporarily increases renal load.

Do you have a history of deep-vein thrombosis (DVT), embolism, or any clotting disorder?

Are you currently taking blood thinners or anti-coagulant medication? e.g. Warfarin, Apixaban, Rivaroxaban, Clopidogrel, daily aspirin.

Section FiveInfection, Fever & Acute Illness

Do you have a fever, cold, flu, or any active infection at the time of your appointment? Lymphatic drainage circulates pathogens — please reschedule if unwell.

Do you have any open wounds, recent burns, dermatitis, or skin infections in the area to be treated?

Section SixSurgical & Oncology History

Have you had any surgery within the past 6 months? Please bring your surgeon's clearance letter to your first session.

Have any of your lymph nodes been removed, biopsied, or irradiated? e.g. axillary clearance, sentinel node biopsy.

Have you been diagnosed with any form of cancer, currently or in the past? Including in remission. We require GP/oncologist clearance for active or recent cases.

Section SevenOther Conditions

Do you have diabetes? Type 1 or Type 2.

Do you have any thyroid condition?

Do you suffer from epilepsy or any neurological disorder?

Do you have any allergies — to oils, fragrance, latex, or medications?

Do you have any implants, pacemakers, metal pins or contraceptive coils?

Section EightYour Goals

Section NineConsent & Declaration

These confirmations protect both you and the clinic. Please take a moment to read each one carefully. If anything is unclear, leave it unticked and Grace will speak with you about it before your first session.

Your treatment will be carried out by Grace Oxley, founder and lead practitioner at Gracious Contours, our private clinic in Seaham, County Durham. Grace will be your single point of contact from consultation through to aftercare.

Before any treatment begins, Grace will walk you through what each session involves, the sensations you may experience, the limits of what the technique can achieve, and any reasonable alternatives. Manual lymphatic drainage and non-surgical contouring are gentle, supportive therapies — they are not medical procedures and they are not a substitute for medical care. Like any therapy involving the body, individual response varies, and no specific outcome can be promised.

The medical information you share above is the foundation of safe treatment. You confirm that the answers you have given are full and accurate to the best of your knowledge, and that you will tell Grace before each session if anything has changed — a new medication, a recent illness, a planned procedure. Where information has not been disclosed, the clinic cannot be responsible for outcomes that arise from it.

How we hold your information. Gracious Contours is the data controller for the personal and health information you have shared on this form. We use it for one purpose only: to deliver safe, considered treatment and the care that surrounds it. Your records are stored securely and never shared without your consent, except where required by law. You may request access to your data, ask for it to be corrected, or ask for it to be erased at any time, in line with UK GDPR. Full detail is set out in our Privacy Policy.

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