Massage Consultation Form

Name(required)

Email(required)

Contact Number(required)

Emergency contact/telephone(required)

Age, occupation, number of dependents?(required)

Do you have a particular focus for your massage treatment? How are your stress levels, sleep patterns, overall well-being?(required)

Do you have any of the following: heart condition, cancer or benign tumour, epilepsy, diabetes, AIDS, MS, ME, recent post-operative conditions, swelling or oedema?(required)

Are you pregnant? Are you currently receiving any medical treatment or taking medication?(required)

Do you have any muscle or joint problems?(required)

Do you have any skin conditions, allergies or sensitivities, breathing problems?(required)

Please check with your medical practitioner before coming for massage if you have any medical conditions. Please sign below to show that you have read and understood these questions.(required)

Your GP details:(required)

The treatment room is on the first floor. Please let me know if this is a problem and I can make arrangements to suit you.

PARKING ARRANGEMENTS: the driveway is beyond the Studio, up a concrete drive where you can park on the left by the barn. Walk back down the lane to the garden door and let yourself into the Studio.

Massage Consultation Form

@HannahLovegrove

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