Massage Pre-Appointment Questionnaire

Massage Pre-Appointment Questionnaire
First time appointments: Please complete consultation form on-line before you visit to save you time. If you arrive late please note that your session might get shortened to accommodate other appointments. If you have a GIFT VOUCHER please type voucher code in booking notes.
Medical Information
Do you currently have or had in the past any issues related to any of the following (please specify)? *

Blood clots Heart disease Varicose veins Lymphedema Allergies Diabetes Skin condition Epilepsy Cancer Fractures Sprains / strains Arthritis Pregnancy None of the Above Other
Treatment Preferences
What type of massage would you like to receive? *

Deep Tissue Massage Sports Massage Back, Neck & Shoulders Swedish Massage Relaxing Aromatherapy Massage Hot Stones Massage Other
COVID – 19 Disclaimer

Following the COVID-19 pandemic, I’ve put extra measures in place for your safety. Please read and answer the below questions. This information will be stored confidentially and securely for 21 days. If you or a member of your household has developed a cough, fever, breathlessness, please contact me before your appointment so I can obtain further information from you and advise.
Are you experiencing a cough? *

Yes No
Are you experiencing a shortage of breath? *

Yes No
Have you had a fever (above 37.7C degrees) in the last 14 days? *

Yes No
Have you noticed a loss or change in your sense of taste or smell? *

Yes No
Have you had any contact with anyone that has suspected COVID-19 in the last 14 days? *

Yes No
Any Other Remarks or Information
If you have any other information you feel is important for LondonMassage4U to know, please use the space provided to detail them.
Client Agreement
I have understood, read and completed this form truthfully to the best of my knowledge. *

I agree
I knowingly and willingly consent to having services at LondonMassage4U during the COVID-19 pandemic. I consent for the services to be carried out which involves a staff member of LondonMassage4U being in physical contact with me less than 2 meters distance. I confirm that I, my household or social bubble have not been in contact with anyone that has had symptoms of COVID-19 in the last 14 days. To prevent the spread of the virus and protect each other I confirm that I will strictly follow LondonMassage4U guidelines. If guidelines are not strictly followed I understand that LondonMassage4U has the right to cancel the appointment with the full cost of the service being charged and any other paid costs being non-refundable. I confirm that I release the staff member performing the service and LondonMassage4U as a business from any and all liability for the unintentional exposure or harm due to COVID-19. *

I agree
I authorise LondonMassage4U to perform the treatment and use lotion/oil on my body. I acknowledge that this massage therapy has no sexual intent. I release LondonMassage4U from any responsibility in case of accident, illness or injury. I acknowledge that all information provided in this form is true and accurate. *

I agree
Client Contact Details
Name *

First Name Last Name
Email *
example@example.com
Contact Telephone Number *
Please supply the best number to contact you on if we need to discuss the information provided.
Address *

Street Address

Street Address Line 2

Town / City County

Postal Code
Signature *

Clear
The answers I’ve given are true and correct to the best of my knowledge. *

I confirm
Should be Empty:

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Massage Pre-Appointment Questionnaire

Medical Information

Treatment Preferences

COVID – 19 Disclaimer

Client Agreement

Client Contact Details