JemmaCo Consultation Form
Street Address Line 2
State / Province
Postal / Zip Code
Check the conditions that apply to you now or in the past:
None of above
Are you currently taking any medication?
Do you have any allergies?
What is the your main reason for treatment?
How do you wish to feel from your treatment?
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
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
I agree to the above information being accurate and to the best of my knowledge.
Should be Empty: