JemmaCo Consultation Form
Full Name
*
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
DOB
-
Month
-
Day
Year
Date
Check the conditions that apply to you now or in the past:
*
Asthma
Cancer
Cardiac issues or disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Pregnant
Hernia or abdominal issues
History of Blood Clots or thrombosis
Kidney function issues
Recent fever or infections
Other
If you have selected any of the above please provide more detail on the condition/s
Are you currently taking any medication?
*
Yes
No
Please list any medication
Do you have any allergies?
*
Yes
No
Other
Please list allergies
Which Treatment are you having?
Detox Massage
Pregnancy Massage
Mix and Match Massage
Acupressure Massage
What is the your main reason for treatment?
How would you explain your general health
Please include your stress levels, diet, lifestyle, water intake, and amount of exercise.
How do you wish to feel from your treatment?
Harmonised
Revitalised
Relaxed
Details of tension or pain areas: please specify areas on your body and the type of discomfort experiences.
For example: Sharp / Pulling / Tender / Intense / Shooting / Aching
Please select up for 3 Options to include in your massage and type in the box. If you wish to discuss with your therapist please write discuss
Rows
Please write your requirements
Heat (Hot stone/ Warm Bamboo / Heated Pads)
Chakra Balance (Sound / Healing / Dowser)
Acupressure ( Feet or Face)
Is there anything else we should be aware of? If none leave blank
Declaration
*
I agree to the above information being accurate and to the best of my knowledge.
Signature
*
Submit
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