Client Consultation Form

Name(required)

Email(required)

Contact Number(required)

Emergency contact/telephone(required)

Age & Occupation(required)

Do you have a particular focus for your massage treatment, or is it for your overall well-being?(required)

Do you have any of the following: Hypertension; Heart Disease; Cancer or Benign Tumour; Epilepsy; Diabetes; Meniere’s Disease; Detached Retina; AIDS; MS; ME; recent post-operative conditions; Depression?(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?(required)

How would you describe you skin type?(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)

The treatment room is on the first floor. Please let me know if this is a problem for you.

Client Consultation Form

@HannahLovegrove

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