Little Self Care Studio. Massage Consultation Form
Please complete this form to help us tailor your massage session to your needs.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you received professional massage therapy before?
*
Yes
No
What is the main reason for your visit or your goals for this massage session?
*
Do you have any current medical conditions, injuries, or areas of pain? Please specify.
*
Are you currently taking any medications? If yes, please list them.
*
Do you have any allergies (including to lotions or oils)?
*
Preferred massage pressure
Light
Medium
Firm
No preference
Are there any specific areas you would like the therapist to focus on or avoid?
*
Accuracy Declaration
*
I confirm that the information I have provided is accurate and complete to the best of my knowledge.
Consent to treatment and Data Processing
*
I consent to Little Self Care Studio by Emma collecting and processing my personal and health information for the purpose of providing safe and appropriate massage treatment. I understand that this information will be stored securely and handled in accordance with the privacy policy.
I understand I can withdraw my consent at any time by contacting hello@emmaselfcare.com
Privacy Policy
*
I have read and understand the privacy policy and how my data will be used and stored. Your data will be stored securely and retained for up to 7 years in line with legal and insurance requirements.
Electronic Signature
*
Submit
Should be Empty: