Buccal Massage Consultation Form

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Health History (check all that apply)

Oral & Dental Health (check if apply in the last 6 months)

Skin & Facial Conditions

Contraindications (Are You Currently Experiencing?)

Buccal Massage-Specific Questions (What are your goals for today's treatment?)

Please list any allergies to skincare products, oils, latex, gloves, medications, ect:

Please list any medications, supplements, or treatments:

Informed Consent:

~ Buccal massage involves both external facial massage and intraoral (inside the mouth) massage techniques performed while the practioner wears gloves.

~Buccal massage is intended to promote relaxtion, improve circulation, reduce muscular tension, and support facial wellness.

~Buccal massage is not a substitute for medical, dental, or psychological treatment.

~I understand that results may vary and no guarantees have been made

~I agree to inform my practioner of any discomfort during treatment.

~I have disclosed all known medical conditions and recent procedures that may affect my treatment.

~I understand that treatment may be modified or declined if contraindications are present.

Consent

Signature

Date