New Client Form

New Client Form

www.rainbirdrelaxation.com
The information in this form will help me create a personalised plan for your massage treatment.

All details provided will be kept confidential and stored securely in accordance with GDPR regulations.

If you have any questions or concerns, please don't hesitate to contact me: anita@rainbirdrelaxation.com
Name*

First NameLast Name
Email*
Phone Number*
Address*

Street Address Line 1

Street Address Line 2

CityCounty

Postcode
Date of Birth*
Please use the format: DD/MM/YYYY
Occupation
Please share your occupation or primary daily activity. This helps us understand your lifestyle and any potential areas of tension.
Do you currently have any areas of pain, tension or discomfort?
Have you had any injuries, surgeries, or significant medical procedures in the last 3 years or, further back, any conditions or events (e.g. heart bypass, joint replacements, accidents, etc.) that would be helpful for me to know about in relation to your treatment? Please feel free to share any details you think are important.
Please check all that apply. (This helps ensure your treatment is tailored to your needs.) If you’re unsure about any of these, or if you have any other concerns, please let me know.

PregnantHeart conditions (e.g. heart disease, arrhythmia)High or Low Blood PressureSkin conditions (e.g. eczema, psoriasis, rashes)Varicose veinsFever or infectionAsthma or respiratory issuesCancer or undergoing cancer treatmentMuscle or joint disorders (e.g. arthritis, fibromyalgia)Epilepsy or seizuresDiabetesBlood clots or clotting disordersAnxiety/Stress/DepressionAny other conditions or concerns you’d like to mention
If you answered "Yes" to any of the above, you can provide more details here:
Please list any medications, supplements, or herbal remedies you're currently taking: (This helps me tailor your treatment as some medications or supplements can affect your skin, muscles, or overall health, and knowing this information allows us to avoid potential risks like skin irritation or bruising.)
Do you have any allergies or sensitivities (e.g. nuts, dairy, fragrances, latex, etc.)? Please specify any relevant details, as this could be relevant for certain products or treatments.
Is there anything I can do to help make your experience more comfortable or accessible? (For example, assistance with positioning, mobility needs, or any concerns you may have.) Please feel free to share any anxieties or specific requirements.
Emergency Contact: In case of any unforeseen circumstances during your treatment, please provide an emergency contact. This ensures your safety and well-being.
Emergency Contact's Phone Number*
MASSAGE MEDIUM
Rainbird Relaxation sometimes uses Songbird Naturals massage waxes, which are 100% natural and contain a range of essential oils. These products incorporate some of the benefits of aromatherapy into the massage. When you arrive, you'll have the opportunity to choose from a selection of soothing scents, including Connect, Lavender, Mountain Forest, Orange Spice, Pacific Nights, and Unscented, to make your experience even more personalised.

More information about the ingredients can be found here: Songbird Naturals Massage Wax.

INFORMED CONSENT
I confirm that the information provided here is accurate and complete. I understand that I am choosing to proceed with massage therapy without prior confirmation from my GP or consultant, and I do so at my own risk. I acknowledge that I have been informed of the ingredients in the massage products used, and I accept responsibility for any allergic reactions or sensitivities that may arise. I understand that I have the right to ask any questions, discontinue the session at any time, and inform my therapist if I feel any discomfort. By signing below, I agree not to hold the massage therapist responsible for any adverse reactions that may result from the treatment.

CONSENT TO USE OF PERSONAL DATA
I consent to providing my contact details for the purpose of booking and managing my treatments. I understand that my information will not be shared with third parties. I may occasionally receive special offers or updates, but I will not receive any unsolicited communications.
Please type your name below to acknowledge and confirm the above information.
Your Full Name
Rainbird Relaxation is a trading name of Rainbird Enterprises Ltd.

Directors: Anita Boole and Warwick Boole
VAT Registration No. 341248031
Registered Office: Rose Cottage, Llandow, Cowbridge, Vale of Glamorgan CF71 7NT
Incorporated in England and Wales Registered No.10934105
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