Full Name
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First Name
Last Name
Date of Birth
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Phone Number
Please enter a valid phone number.
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.
How many minutes would you like the appointment to be?
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
Which trimester?
First trimester
Second trimester
Third trimester
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.
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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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