Massage Client Information and Consent Form

    Personal Details:

    Name:

    Surname:

    Date of birth:

    Email:

    Phone:

    Where did you hear about us?

    Location and venue name. Where you are taking your therapy now?

     

    Personal health information. Please give details of any health concerns:

    Including bruises, sprains, recent operations etc; whether you are receiving treatment from any healthcare professional; and of any medications you are taking. Massage is not a substitute for medical treatment.

     

    Do you have any of the following?

    * Heart Condition:
    * Arthritis:
    * Thrombosis:
    * Rheumatism:
    * Epilepsy:
    * Osteoporosis:
    * Diabetes:
    * Pregnant (Or Trying):
    * High/Low Blood Pressure:

     

    Disclaimer: It is your responsibility to let me know of any condition for which you are receiving medical treatment. I am not a medical practitioner and do not diagnose or treat medical conditions.

     

    My commitment to you is that I will give you the best treatment I can. I will only ask you specific questions each time to help me decide on the best treatment for you and to assess the effectiveness of the treatment afterwards.
    I will ask you at the start of each session to focus your mind on your outcome; and on breathing, feeling and releasing – to help you get the most benefit from the session.

     

    I confirm that I have given complete and accurate information and that I consent to receive Massage.

     

    Date you submit this form

     

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