Initial Consultation Information Form
Thank you for booking a massage at Stop For A Massage. Please could you complete this confidential form for Stop For A Massage to ensure I give you the best possible safe massage. It should only take a moment to complete. Please give as much detail as possible as some medical conditions mean it is not safe to receive massage. To return it just click the submit button at the bottom of the form. Please only submit the form if you agree to the privacy statement at the bottom of the form. You can read more about how I protect your data on the privacy page of my website. Thank you, kind regards, Liz.
Name *
Your answer
Date of appointment *
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YYYY
Phone/Mobile *
Your answer
Have you have any injuries, operations or illnesses? If the answer if yes, please give details, particularly how it affects you. *
Your answer
Do you have any areas of your body causing you discomfort? If yes, please give details. *
Your answer
Do you have any problems with your joints, bones, blood pressure, circulation, skin, breathing, digestion or heart? If yes, please give details. *
Your answer
Are you pregnant? If yes, please give details eg How many weeks? Have you experienced any problems, pain, bleeding? *
Your answer
Do you have any allergies? If so please give details. *
Your answer
On a scale of 1 to 10 how stressed are you today? *
Your answer
I understand that Liz at Stop For A Massage will receive this information through Google Drive. Once received the information will be transferred to paper copy and stored securely. Your information will then be deleted from Google Drive.The phone number will be stored on her phone for any necessary communication with you before your appointment. If this is not acceptable to you please do not submit the form, and contact Liz by phone, as it is important that Liz is able to discuss relevant medical details with you before you attend your appointment. Thanks *
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