Client Massage Pre-treatment Form
This confidential form is necessary for us to ensure the treatment we provide is suitable for you and allows us to tailor the treatment to your specific needs. We may want to discuss some of your answers below with you during treatment to help us better understand your condition or how we may adapt the treatment for you. The details below are completely confidential and we will not share your details below with anyone else without your consent.
If you are experiencing any of the following please contact us to POSTPONE your appointment for at least TWO WEEKS after you are better:
LOSS OF TASTE AND/OR SMELL
If you have been in contact with anyone who has had the above symptoms or has been confirmed with Covid19, please postpone your appointment for 2 weeks.
There are no penalties for postponement of appointments.
We advise clients to wear a mask for their appointment and to come alone. Please arrive on time and no more than 5 minutes early. Please bring your own water.
For further information on how we are keeping you safe please see our website-
I have read and understood the Covid19 policy outlined above and will adhere to the conditions above for my appointment.
Date of birth
Mobile phone number
Doctors name and contact details
Primary reason for treatment
Pain relief and/or rehab
Health History- Please tick any conditions you are currently suffering from or have a history of.
Any skin conditions that may be affected by the treatment, eg eczema, psoriasis, or contagious skin conditions such as Ring worm, Impetigo
Thrombosis or varicose veins
Any heart conditions
Diabetes or any condition affecting skin sensitivity
Undergoing treatment for a long term illness eg Cancer
Arthritis- Osteo or Rheumatoid
degenerative muscular conditions
IBS or digestive disorder
Pregnant- Please ntoe we cannot treat you before 12 weeks
Recovering from surgery
Any undiagnosed pain- sport injuries, limb injuries
Any undiagnosed inflamation or Oedema
Taking medication, other than contraception.
Anxiety or depression
Insomnia or interrupted sleep
Allergies- Including NUT allergies as some of our products can contain nuts however we can adapt the products used, where necessary.
If you ticked any of the boxes above, please use this space to expand futher- details of any medication, areas of discomfort or pain, details of any injuries or surgery, details of any restrictions of movement.
Please add below any requirements you have for the treatment including pressure preference and areas to focus on.
In completing this form above, I agree to my treatment and have disclosed any medical information that may be affected.
Many thanks for completing this form. If you have any qustions you can contact us on
We look forward to seeing you for your appointment.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Rest Massage & Beauty.