Clone of Massage - Therapy Consultation Form

Please answer the following questions to enable us to give a safe and effective treatment, and if necessary to obtain approval and advice from your doctor. Any information is treated in the strictest of confidence and no advice with be sought without your prior permission.

Full Name

First NameLast Name

Date of Birth

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Occupation and Hobbies

Medical History

Please check any of the symptoms that apply to you:

Please check if you have every suffered from the following:

Please check if you have suffered from any of the following in the last 6 months:

Please check if you currently suffer with any of the following:

Medications (if any)

Allergies (if any)

History of Pain

Please circle any areas of stress, tension or discomfor:

Annotate Image

Details of injuries (if any)

What type of music would help you relax during your session?

Client Agreement:

I confirm that the above information is accurate to the best of my knowledge and that I am happy to undergo treamtment by a licensed massage practitioner. I will advise the practitioner of any changes to the above details prior to any future appointments.

Cancellations the day before within 24 hours of the appointment start time will incur a 50% charge.
Cancellations 24 or more hours in advance will incur no charge.

By my electronic signature below, I agree to the massage policy and client agreement above.

Signature/ (parent/guardian please sign here)

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Questions?

Date

MonthDayYear