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Remedy Massage Consultation Form
Thank you for booking your treatment with Remedy Massage. Now that you have read through all of the new COVID-19 procedures -
https://remedymassage.weebly.com/covid-policies.html
, ahead of your appointment with me, please complete the following consultation form. I look forward to seeing you.
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PERSONAL INFOMATION
Full Name
*
Your answer
Email Address
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Home Address
Your answer
Phone Number
Your answer
Emergency Contact Name and Number
*
Your answer
COVID-19 SPECIFIC QUESTIONS
Have you been in contact with anyone who has been diagnosed with, or has symptoms of, Covid-19 in the past 14 days, to your knowledge?
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Yes
No
Have you had any of the following symptoms in the past 14 days: dry cough, temperature over 37.8°C, loss of smell and/or taste?
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Yes
No
Are you considered a vulnerable person who needs to shield during the isolation period (or are you living with a vulnerable person who is shielding?)
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Yes
No
Please confirm the following by checking the appropriate boxes
*
I will inform Shauna prior to treatment if I develop COVID-19 symptoms to reschedule
I am happy for Shauna to contact me if anything on this form needs discussing further.
I will bring and wear a mask prior to, during and after my appointment.
Required
TREATMENT SPECIFIC QUESTIONS
What are your goals for this massage therapy session?
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Relaxation / Wellbeing
Muscle Tension / Pain Relief
Other:
Required
What physical activities are you doing during the week and are there any specific areas that you would like me to focus on?
*
Your answer
If you'd like to show specific areas, you can print out, circle areas on the model below and return to
shaunaremedymassage@gmail.com
before you session.
Do you have any music or aroma preferences during the massage?
*
Your answer
Do you have any allergies?
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Yes
No
If yes to the above, please expand upon this here.
Your answer
Do you have any prior injuries or medical conditions (particularly high or low blood pressure, thrombosis, epilepsy, diabetes, HIV etc...) that I need to know about?
*
Yes
No
Required
If yes to the above, please expand upon this here.
Your answer
Please type your name and date below to confirm that you consent to the treatment with Shauna and have completed this form to the best of your ability and knowledge.
*
Your answer
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