Massage Therapy Intake, Health, and Booking Form
Please complete this form to provide your details, health information, and book your massage session. This form does not guarantee your appointment - It is request only and pending availability.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Have you received professional massage therapy before?
*
Yes
No
What is the main reason for your visit today? (e.g., relaxation, pain relief, injury recovery)
*
Are you currently taking any medications? If yes, please specify.
Do you have any allergies (including lotions, oils, or scents)? Please specify.
Are there any areas you would like the therapist to focus on or avoid?
Preferred session duration
*
Please Select
30 minutes
45 minutes
60 minutes
90 minutes
Other
What is your gender? (Note: This service is female-only)
*
Female
Male
Other
Do you agree that this service is strictly non-sexual and professional?
*
Yes
No
PARQ: Do you have, or have you ever had, any of the following conditions? (Check all that apply)
*
Heart condition
High blood pressure
Low blood pressure
Diabetes
Epilepsy or seizures
Blood clots
Recent surgery
Skin conditions
Pregnancy
None of the above
Other - please state below in the other information box
Have you had any metal work or surgeries in the last 6 to 12 months?
*
Yes
No
Do you agree to the 48 hour cancellation policy and understand that a 50% deposit is required to secure your booking slot?
*
Yes
No
Is there anything else you would like your therapist to know?
Massage Therapy Services
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Back, Neck & Shoulders Massage - Invigorating or Calming
30 mins
£
33.00
Indian Head Massage - Release Tension, Sensory Calming
45 mins
£
44.00
Swedish Massage - Classic, Full Body, Relaxation
1 hr
£
44.00
Paraffin Wax Massage Treatment - Warm Wax used for replenishing the skin, helps ease aches and pains
45 mins
£
49.50
The NeuroModus Method™ - A science informed massage designed to calm the nervous system
1 hr 15 mins
£
63.80
Aromatherapy add on
Why not add the soothing scents of essential oils to your massage.
£
5.00
Quantity
1
2
3
4
5
6
7
8
9
10
Appointment
I am a qualified massage therapist and will exercise reasonable care and skill during treatment. Clients must disclose all relevant health information and understand that massage therapy outcomes cannot be guaranteed. Clients agree to follow all aftercare instructions and maintain good personal hygiene, including showering before appointments. Please do not attend your appointment if you have a cold, flu, or have been unwell in the past 7 days. While I strive to provide safe and effective treatment, liability is limited to the extent permitted by law.
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