Consultation Form
All details will be kept confidential and will not be shared in line with the data protection act.
Client Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Profession
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
*
How did you find out about us?
*
I.e. Facebook, Instagram, Friends, Family, etc
Health Data
Describe the reason for your attendance?
*
What treatment have you booked in for? ie. Sports Massage, Deep Tissue, Reflexology etc
*
Have you recently seen your GP or been hospitalised? If yes, please expand.
*
Do you have any recent injuries?
*
Are you currently taking any medications?
*
Do you have any allergies?
*
Have you recently seen a health care practitioner ie. chiropractor, osteopath etc?
*
Please advise if you suffer from any of the following conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
*
Please describe your lifestyle, hobby's, etc.?
*
Have you had a massage before?
*
Please describe expectations from the treatment?
*
Please provide any further information you think might be relevant and not asked above?
*
Location of the painful area(s)
*
Cancelation policy
If you are unable to attend your appointment, please let us know 48hr in advance and we can reschedule your appointment and fill your time slot. You may be liable for the cost of the treatment if you miss or cancel your appointment late. We kindly thank you in advance for observing this policy.
Consent Declaration
Anyone under the age of 18 will need an adult to be present for the duration of the treatment.
*
I authorise the use of massage medium ie oil, lotion, wax etc. to my body.
I acknowledge that certain health conditions require medical approval before undergoing any "massage" treatment.
I understand that this is an alternative/complementary treatment (not sexual) and if there are any medical concerns, I need to talk to my physician.
I confirm that the information given above is correct and that to my knowledge, I have not withheld any information that may be deemed relevant to my treatment. I will notify the therapist of any future changes in my health before receiving further treatments. I accept full responsibility for any problems arising from my omissions on this form, including relevant health conditions, medications and ongoing medical treatments.
Signature of the Client
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
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