Massage Client Consent & Health Screening Questionnaire

First Name

Last Name

Contact Number:

Contact Email

Date of Birth:

Occupation:

Address

Address Line 1

Address Line 2

City

Country

Select

Postcode

Emergency Contact Name + Phone Number:

Please provide details/relevant info here:

Are you under the current care of a doctor/health professional? If yes, please give details

Current concerns in your body, health, well-being? If yes, give details

Goals for your massage treatment? How would you like to feel?

Preferred day/s for massage?

Checkbox Description

Wednesday
Thursday
Friday
Saturday

Preferred time of day ?

Checkbox Description

Morning
Afternoon
Evening

By signing below, I agree to participate in a class/program. I have answered the Health Screening Questionnaire truthfully, with
my most accurate knowledge, that I am well to take part. I undertake to inform
Therapy by Alice Mooney of any alteration to the above information. I
understand that my personal data will be stored securely and confidentially.

Client Signature

To accept this agreement, type your name below

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Massage Client Consent & Health Screening Questionnaire

Thank you for contacting Therapy by Alice Mooney