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NEW CLIENT INTAKE FORM

If you are a new client, please take a moment to carefully fill out this form.

If you tick “yes” to any of the following conditions, please explain as clearly as possible.

If you have a specific medical condition, or symptoms of medical condition, massage may be contraindicated.

A clearance from your GP to receive massage therapy may be required prior to massage service being provided.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Your phone number

your Email *

Confirm your Email *

treatments, If scents)?

Your address

Your date of birth (dd/mm/yy)

Your occupation

Sports / Exercise / Hobbies

Emergency contact *

First

Last

Emergency contact - phone number

Relation

Your GP's name

What type of treatment are you seeking?

Holistic massage
Hot stone massage
Aromatherapy massage
Pregnancy massage
Reiki Usui

Have you ever had a professional massage?

Yes
No

What pressure do you prefer

Light
Medium
Deep
Don't know

Are you allergic or sensitive to any oil ( essential oils, nut oils, scents)? If yes, please list:

I usually use organic sesame oil for massage

Are there any areas (face, feet, abdomen, etc) you don't want massaged? If yes, please specify

Are you taking any medications? *

Yes
No

If yes, please list and name and reason:

Are you currently pregnant? *

Yes
No
Not applicable

If yes, how far long? (number of weeks)

Any risk factors?

Are you currently breastfeeding? *

Yes
No
Not applicable

Please check all that apply to you:

Is there anything else you would like me to know?

General Data Protection Regulation (GDPR) *

"I consent to my medical and treatment records being stored and processed securely in compliance with current GDPR regulations"

(Please understand that if you decline to give the above permission I will unfortunately be unable to deliver any services to you)

I would like to receive occasional emails and/or text messages about special offers, new treatments, and appointment availability. I understand that I can unsubscribe or update my communication preferences at any time. *

Yes
No

(This is completely voluntary and you are under no obligation to agree. This will not affect how I treat you)

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