Now & Zen Mobile Massage – Client Intake & Consent Form
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First Name
Last Name
Date of Birth
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Day
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Month
Year
Date
Phone Number
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Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
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Emergency Contact Number
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Booking date
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Day
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Month
Year
Date
Your Massage Preferences
Treatment Type
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Please Select
Relaxation
Deep Tissue
Sports
Pregnancy
Remedial (rebates may or may not apply depending on therapist)
Preferred Pressure
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Please Select
Light
Medium
Medium - Firm
Firm
Areas to focus on
Back
Neck
Shoulders
Legs
Arms/Hands
Areas to Avoid
Health Information
Do you currently have, or have you previously had any of the following? Select all that apply.
Please select any that are relevant
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Recent surgery (6 months)
Chronic pain or injury
Heart Condition
Blood pressure issues
Diabetes
Skin Conditions / Infections
Allergies
Varicose Veins
Headaches / Migraines
Stress/Anxiety
Cancer Treatment (if relevant)
Blood Clots / DVT
None of the above
Other
If any of the above were selected, please provide more details including areas affected and any relevant treatment or advice from your healthcare provider.
Medications
Are you currently pregnant?
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Yes
No
How many weeks?
If Pregnant, are you comfortable laying on your side?
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Yes
No
Lifestyle
On a scale of 1-5 what is your current stress level? (1 = very relaxed, 5 = extremely stressed)
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Occupation
How many times per week do you exercise?
Professional Boundaries
Our services are strictly professional. Any inappropriate behaviour will result in immediate termination of the session. Do you understand and agree to respectful conduct during your session?
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YES
Cancellation Policy
We require at least 24 hours notice for cancellations or rescheduling. Late cancellations or missed appointments may incur a fee.
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I acknowledge this and Now & Zen Mobile Massage full T's and C's as outlined in full at https://www.nowandzen.net.au/terms
Consent & Waiver
REQUIRED - Please read carefully before agreeing:
I understand that massage therapy is for relaxation and general wellbeing and is not a substitute for medical care or advice. I confirm I’ve disclosed all relevant health conditions and will report any changes before treatment. I understand sessions may be modified or declined for safety, and results are not guaranteed. I may request pressure adjustments or stop the session at any time. As this is a mobile service, I agree to provide a safe, clean, suitable environment. The therapist may refuse or end treatment if conditions are unsafe. I consent to treatment and accept responsibility for my wellbeing during and after the session.
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I have read and agree to the above terms
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