Intake Form

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Name *

First

Last

Address Line 1 *

Post Code *

City *

Email *

Phone Number *

Emergency Contact Name *

the Code be

Emergency Contact Number *

Do You Have any Allergies? *

Do you have any of the following? Please check all that apply

• Arthritis
• Osteoporosis
• Varicose veins
• High blood pressure
• Frequent headaches
• Cardiac or ciculatory problems
• Sensory loss
• None

Are you taking any medications? If so, please list:

Have you have any recent injuries or surgeries in the last 2 years? If so, please list:

What pressure level do you prefer?

• Light
• Medium
• Firm
• Unsure

Where did you hear about me?

• Google Web Search
• Google Maps
• Leaflet in a shop
• Friend Referal
• Other

Informed Consent: By checking the following box you agree that the above information is accurate to the best of your knowledge and freely give your permission to be massaged. You agree to inform the therapist of any experience of pain or discomfort during the session. You understand this does not deter you from seeking medical treatment for medical conditions. You understand that no inappropriate comments or conduct will be tolerated. Any indication of such behaviour will immediately end the session. You agree to update the massage therapist in regard to changes in your health (if they would effect the massage) and understand that there shall be no liability on the therapist's part should you forget to do so. *

• I agree

Submit

Please fill in the above form before booking your first session.