Body Massage Consultation Form

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Personal Details

First Name *

Last Name *

Date of Birth *

Address *

Post Code *

Occupation

Email *

Phone: *

Where did you hear about The Serenity Shed?

Recommendation Facebook search engine instagram other

If applicable, who recommended The Serenity Shed to you?

You May contact me by Email for

Appointments Information Marketing All

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G.P. Name

G.P. Practice address

G.P. Phone Number

Emergency Contact Name

Emergency Contact Phone

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General Health

Do you exercise regularly?

Never Occasionally Often

Do you have any allergies? *

If you answered yes to any of the above give details

Are you currently taking any medication? *

No Yes Yes occasionally

Have you had Massage Therapy previously?

Yes No

Reason for last Massage Therapy?

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Just for Her

Could you be pregnant?

Yes No

Are you breastfeeding

Yes No

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Declaration

I declare that the information I have given is true and correct as far as I am aware. I confirm that I can undertake the treatment explained to me by this therapist without any adverse effects. I have been fully informed about possible contraindications, and am willing to proceed. I understand that body massage is not a substitute, for medical advice and or treatment advised by my general medical practitioner.

Clients Signature *

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Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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