Massage Consultation Form Massage Consultation Form Massage Consultation Form FULL NAME To ensure we provide the most tailored treatment To ensure we provide the most tailored treatment Please indicate Please indicate I am a returning guest with no changes to my previous medical profile I would like to complete a full consultation form today Declaration Declaration I verify that my medical information remains accurate as of this date below Last Consultation Date Date format DD/MM/YY Date format DD/MM/YY Declaration Declaration I hereby confirm that I have previously completed a comprehensive consultation at Si Belle Salons, Richmond. I acknowledge that it is my responsibility to inform my therapist of any new health developments or prescribed medications. Today's Date Date format DD/MM/YY Date format DD/MM/YY Date of Birth (DD/MM/YY) Contact No Email GP DETAILS Contraindications Contraindications Please tick any that apply Please tick any that apply Covid-19 Symptoms Undiagnosed Migraine Rashes / Severe Sunburn Heart Conditions Allergies Cuts, Wounds or bruises Recent injuries deep vein thrombosis undiagnosed pain infections, contagious diseases high/low blood pressure active tumours blood disorder pregnant herpes Recent surgeries under influence of alcohol or recreational drugs rheumatoid arthritis NONE OF THE ABOVE Please describe further medical history or medications How would you like your massage pressure? How would you like your massage pressure? LightMediumfirm Declaration Declaration I understand that failure to disclose information requested above may result in adverse side effects from treatment(s) received and therefore I accept full liability/responsibility for the information given. Today's Date Date format DD/MM/YY Date format DD/MM/YY 4 + 1 = Submit
