Marios Massage Therapy - Initial Consultation form

Marios Massage Therapy

Initial Consultation form
Thank you for booking a massage with me.

To best meet your needs safely during the massage, please complete this confidential form. All fields marked with * are required. Thank you.
Name*
Mobile number*
D O B*

DayMonthYear
Home Address:*
Email Address*

Confirmation EmailConfirm emal address
Have you had any previous massage or bodywork sessions?
Are you currenty on any medications?*
Because you've answered "Yes" above please provide additional info (why, for how long)
Medical History - any sprains, strains, breaks, hospitalisations recently?*
Please tick the boxes below if they apply to you

Osteoporosis or bone conditionJoint condition (Osteoarthritis, etc)Skin conditions (Eczema, etc)breathing condition(Asthma, Bronchitis, etc)Digestive Condition (IBS, reflux)Cardiovascular condition(Varicose veins, high/low blood pressure)AllergiesHeadachesPregnant
If applicable, please list any areas of discomfort in your body.
Any other comments which may be relevant for our session?
Is there any particular benefit you would like from the massage?
I hereby consent to a massage treatment as agreed between myself and Mario. All information provided above is accurate and current at the time of submitting the form.

I agree for Mario to hold my relevant information in accordance with GDPR.
Date:*

DayMonthYear
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