Massage Contraindications

Massage Health Form
Title

MrMrsMissMsDrNone of the above
Name*

First NameLast Name
Gender*

FemaleMaleTransgender FemaleTransgender MaleGender variant / non-conformingNot listedPrefer not to answer
Date of birth*

MonthDayYear
Date
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Emergency Contact

First NameLast Name
Emergency contact phone number

Area CodePhone Number
Health
Are you suffering with any of the following?

AllergiesCancerDiabetesEpilepsyHeart conditionsHigh/Low blood pressureLong term illness
Further information
Please use this to provide any further information
Are you suffering with any of the following conditions?

Back problemsEczemaIBSDepressionArthritisHperthyroidMigrainesConstipationAsthmaPsoriasisClaustraphobiaRheumatismMenopause
Further information
Please use this to provide any further information
Skin types and concerns

NormalDryCombinationOilynessDullnessPigmentationCongestionSensitivityAcneFine linesHigh colourSun damageDark circles/puffinessOther (please use field below)
Further information
Please use this to provide any further information
Medical history
Please use this to provide any further information
Address of doctors surgery

Street Address

Street Address Line 2

City

Postal / Zip Code
Are you or could you be, pregnant, or have you given birth in the last six weeks?*

NoYes
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In order to comply with the General Data Protection Regulations, it is necessary for me to check whether or not you are happy for me to retain your contact details, and to send you information that I think may be useful to you, including training and events, and relevant updates. I only hold information when it is necessary to do so in order for me to carry out my work, and when you have given me permission to do so. To ensure that I only communicate with you in the manner of your preferred choice, please will you indicate below, your agreement, or otherwise, to the following means of communication:
Contact perferences

PhoneEmailPost
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Massage Health Form

Health

GDPR Statement