Consultation Card – Therapeutic Massage by Roxanne

Name and Surname

Phone

Gender

Age Group

Emergency Contact Person and Phone Number

Have you had a massage before and what was the reason?

What is your main reason or area of concern for the massage?

Are you on any medications? If yes, please specify.

Have you had any major surgery in the last 6 months? If yes, please specify.

Have you had any major bone or muscle injuries in the past? If yes, please specify.

Please select below if personally have had any of the conditions mentioned below:(required)

Have you had pregnancies in the past?(required)

Yes, 1 Yes, more than 1 No Not Applicable

Are you currently pregnant or breastfeeding?(required)

Yes, pregnant Yes, breastfeeding No Not Applicable

Do you exercise? (required)

Yes No

If you answered Yes to the above question, please explain.

Are you preparing for any major event? If Yes, please explain.

Are you allergic to anything? If Yes, please explain.

Please list any medical conditions which you currently have.

Please advise on any major illnesses or medical conditions which you have had in the past.

Please list any medication which you are currently taking.

Type of treatment you wish to have:(required)

Therapeutic / relaxation / remedial massage Sports / deep tissue massage Facial lymphatic drainage massage Body lymphatic drainage massage Pressure point reflexology foot massage

Please confirm that you have not taken any drugs (recreational or medicinal) within 48 hours (2 days) prior to your treatment:(required)

Yes No

Please confirm that you will not be under the influence of alcohol at your treatment:(required)

Yes No

If you require a statement for medical aid reimbursement, please provide your full medial aid details below, (including: main member name and ID number, patient name and ID number and medical aid name and number) / full payment is due at appointment. You will receive your statement via email to submit to your medical aid, they will reimburse you directly (Ts and Cs apply).

Extra time will not be given if you arrive late for your appointment, this will be taken off the allocated appointment time, and the full price will be charged. Appointments cancelled by the client within 24 hours of the treatment time, will be liable to pay a 50% cancellation fee. No-shows will be liable to pay the full treatment cost before booking their next appointment. New clients who do not show for their appointment will not be allowed to book again.
I hereby indemnify the Therapeutic Massage Therapist (Roxanne Blewett A12292) against any adverse reaction sustained as a result of the treatment. I do not hold the Therapeutic Massage Therapist (Roxanne Blewett A12292) responsible for any negative outcome of this massage Treatment. I agree in entirety to the treatment as described above, including the areas to be worked on. I confirm that at the time of signing this document, everything mentioned is true and correct. Do you agree with the above statements?(required)

Yes No

Thank you and enjoy your massage treatment!

Your message has been sent