New Client Consultation Form

Hot Stone Massage Consultation Form

The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Treatment Required

Hot Stone Massage – 60 minDeluxe Hot Stone Massage – 90 min
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

City

Country
Phone Number*

PrefixPhone Number
E-mail*
Occupation
Emergency Contact Name & Mobile*
Have you have a professional Massage /Hot Stone Massage/ treatment before?*

Yes -Hot Stone MassageYes - Massage OnlyNo
Are you currently attending a GP/complimentary therapist for any condition/treatment?

YesNo
GP / Therapist Name & Address and details of condition / treatment
Current Medication (incl vitamins):*
How did you hear about me?*

Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name
If Other, please let me know where!
I understand that this is for relaxsation purposes only *
Your General Health
Have you experienced any of these health conditions in the past or present?*

Hormone Imbalance (eg PCOS / irregular cycle)CancerHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesSinusitisBack ComplaintsSkin conditionsInsomniaCovid-19Reocurring infectionsTinnitusVertigoPerforated Ear DrumEar AchesSnoreNoneOther
If you checked yes to any of these please provide further information. If not mark N/A*
Stress Levels at Home*

HighMediumLow
Stress Levels at Work*

HighMediumLown/a
Exercise / Hobbies?
Any known allergies (eg: aspirin, latex, nuts, essential oils)?*

Yes*No
*If Yes, please give details:
FEMALE CLIENTS ONLY: Are you / could you be pregnant*

YesNoN/A
Are you a smoker? *

YesNo
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Do you drink alcohol*

YesNo
What is your daily water intake (glasses / litres)*
Have you ever experienced claustrophobia? *

YesNo
Are there any other information you would like to make your aesthetician aware of? If yes, please give details:
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged $50. I have reduced my capacity to see clients so this is vital to my business and to allow for as many clients to be seen.Suspected Covid-19 and severe pregnancy related issues are exceptions to this rule, but please do let me know asap.*

I understand the reservation and cancellation policies at Euphoria 7 Spa
CLIENT DECLARATION: I declare that the information I have given is correct and as far as I am aware I can undertake a treatment with out any adverse effects. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and I am willing to proceed. I understand that complimentary therapies do not substitute medical treatment. If I experience any discomfort during the treatment I will inform the aesthetician immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release Euphoria 7 Spa from liability and assume full responsibility thereof. I understand that my aesthetician may require me to obtain permission from my doctor before my appointment.*

By checking this box I understand and accept this statement
Euphoria 7 Spa will occasionally contact clients to send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for Renew Therapies to:*

Contact you about appointment and relevant follow up.Send occasional emails with news, special offers etc.
Signature*
Thank you for taking the time to complete this form - I look forward to seeing you soon.

Euphoria 7 Spa
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Hot Stone Massage Consultation Form

Your General Health