Full Name
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First Name
Last Name
Date of Birth
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Month
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Phone Number
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Format: (000) 000-0000.
Medical History. Please seek medical advice before receiving treatment if you have ongoing health issues, take prescribed medication, or have not received a massage before.
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Are you currently taking any medications? If yes, please list them.
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Do you have any allergies? Have you experienced a reaction to any oil or essential oils? Do you have a preference of essential oils if choosing an aromatherapy treatment?
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What type of massage are you requesting? i.e Swedish, Aromatherapy, Hot Stones, Wood Maderotherapy, Reiki Seichem
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Please state what parts of the body, including the stomach, face and scalp, you would like included in your treatment.
Pregnant or breast feeding? I do not offer Hot Stone massage to anyone during pregnancy. Essential Oils are to be avoided within the first trimester.
Pregnant
Breast feeding
By signing below, I confirm that I am requesting a massage for muscle relaxation and understand it is not a substitute for medical assessment or treatment. I also consent to the processing and storage of my personal data for consultation and record-keeping purposes.
*
Please note that if you cancel your booking within 48hours of your appointment time I can only refund you 50% of the treatment price.
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