CLINICAL MASSAGE THERAPY

Quick Intake & Consent Form

All information is confidential and required for safe treatment.

1. CLIENT DETAILS

Full Name

Phone

Email

Date of Birth
Format: DD/MM/YY (e.g. 25/12/95)

2. HEALTH SCREENING

Blood pressure issues

Skin condition or sensitivity

Recent surgery or injury (last 6 months)

Neurological condition

Chronic pain condition

Allergies (if any)

3. PREGNANCY (IF APPLICABLE)

Not pregnantPregnant
If pregnant, months:

Prenatal massage requested

BODY MAP – AREAS OF CONCERN

Click on the body area, then select side and level of discomfort.

5. TREATMENT GOAL

Pain reliefInjury recoveryPostural correctionStress / tension reductionMobility improvementGeneral full-body relaxation

6. PRESSURE PREFERENCE

LightModerateDeep (within therapeutic limits)

7. SILICONE CUPPING THERAPY – CONSENT

Yes, I consent to silicone cupping therapyNo, I do not consent to silicone cupping therapy

Please indicate how you were referred to our clinic.

Google SearchSocial MediaReferral from Friend or FamilyOnline ReviewsExisting / Returning ClientWalk-inOther

9. DATA | COMMUNICATION CONSENT (GDPR) | CLINICAL CONSENT

I confirm the information provided is accurate and I consent to receive clinical massage therapy.
I consent to the collection and storage of my personal data for clinical and billing purposes.

Signature (Type Full Name)

Date