Sacred Lotus Treatment Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty

Postal Code

Date of Birth

Date

Email

example@example.com

Phone number

Weight & Height (Massage Couch Reasons)

List any medications, supplements, or herbal remedies you currently take:

Please declare allergies or sensitivities including scent aversions:

Please declare any physical disabilities, injuries or surgeries :

Preferred Massage Pressure?

What are your specific concerns at this time?

What is your stress level right now?

Current nutrition & exercise habits?

What do you consider your skin type?

Postural Faults

What type of treatment have you booked?

Please check all that apply.

Any other information, goals or comments?

By signing below, you agree to the following; I acknowledge that the holistic treatment I have chosen should not be conducted under certain health conditions and declare that I have am physically and emotionally well enough to receive a holistic therapy session and do so at my own risk.

All sessions are absolutely non-sexual and I understand any proposition of sexual nature will not be tolerated and seen as sexual harassment and an attempt to recruit the therapist into sex work. Any attempt to recruit the therapist into the sex industry or prostitution will be reported to the police for safe guarding purposes.

I also agree that if I feel any pain or discomfort during the massage session, it is my sole responsibility to inform the holistic therapist - Kayleigh Burn to give her the opportunity to make adjustments. I, also, will take full responsibility for my body and behavior and consent to release and indemnify staff and any claims or injuries associated with this or any future treatment session.

Please note: If you have had cancer within the last 5 years or are high risk pregnancy then a letter may be needed from a medical professional.

Contact Kayleigh via email at sacredlotusasmr@gmail.com for a copy of this form.

Signature

Date