07736 318857

Consultation Form

General and Medical Information

Your Name (required)


Your Location (required)


Your Email (required)


Your Phone Number (required)


Date of Appointment (required)


Treatment Chosen (required)


How did you hear about Bamboo Massage? (required)


D.O.B. (required)


Occupation (required)


GP Name and Address (required)


Stress Level - 10 being highest (required)


What do you do for relaxation?


Do you do any sport or exercise?


Have you had professional massage before? (required)


Have you had any other professional therapy? (osteopathy, hypnotherapy, counselling etc)


Have you had any recent injuries?


Have you had any surgery in the last 6 months?
 Yes No Yes - over 6 months ago

Do you have any allergies or skin conditions?


Have you ever undergone treatment for cancer?
 Yes No

Do you have a heart condition?
 Yes No

Do you have high or low blood pressure?
 High Low Normal

Are you taking any medication?


Are you pregnant?


If yes, how far along?


Please provide any other medicals conditions or areas of concern here



All appointments are subject to availability. Please note that there is a 24hr cancellation policy.

 

@Bamboo_Massage

Recent Posts

Member of the FHT

fht_logo1

Leave Feedback

Your Name (required)

Location

Email (required)

Your Message

Your details will not be shared with any third parties and you will not be added to any mailing list by filling out this form.

Enter the code to prove you are not a robot!
captcha

© 2021 Bamboo Massage
Developed by Bubblehub Solutions