Personal Information
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First Name
Last Name
Email
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Address
Date of birth
Recorded in US format so month first
MM
DD
YYYY
Phone Number
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New Clients: How did you hear about Massage and Me?
Confirmation of treatment, including date and time
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Emergency Contact Name and Number
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Will you require a parking permit during your appointment?
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IF YES - please confirm your car registration number
Do you suffer from any conditions that require a medical note? (for example, cancer, diabetes, high blood pressure)
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Optional Notes section
Medical Conditions: Do you have any skin disorders or fungal conditions?
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Do you suffer from any allergies? If so please detail below
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Allergy information if required
Extra information about my neurodivergent needs
Personalising Your Treatment
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What is the main reason for your visit?
Is there anything else I should know before your treatment - e.g: How would you like to feel after your treatment, your main areas of tension, the sort of pressure you like
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How would you describe your general wellbeing?
Would you like to join the Massage and Me mailing list?
Declaration and Consent
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This form will be kept on file securely by Jo at Massage and Me, and will not be shared with any third parties.
Terms and Conditions:
- Cancellation: Please try to cancel within 48 hours of your appointment time or try to find someone to fill your slot where possible. If you're poorly, please don't force yourself to come to your treatment as it won't be good for you or me! If you fail to show up for your treatment please pay in full.
- I kindly ask you all to arrive on time for your appointment, though please note if you arrive early I may either be with another client or still be setting up.
- If you are pregnant and under 12 weeks into your pregnancy then I won't be able to treat you.
- I have two cats and so, while they are not allowed in my treatment room, please let me know if you think this may aggravate allergies.
- Payment is taken at the end of the appointment and can be taken by: cash, card or bank transfer.
Please confirm you agree with the following statement:
The information I have provided is correct. I have not withheld any personal or medical information that may affect my treatment. I will adhere to the Massage and Me safety and hygiene guidelines before and during my treatment. I will not hold my therapist, Jo Murch or Massage and Me responsible should I, members of my family or friends become unwell following my holistic therapy treatment.
Please confirm your name and today's date
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