Massage Consultation

Name:

Email:

Phone:

Age:

Occupation:

Address and postcode:

Physical issues to work on? (areas of tension)

Emotional issues you want to work on?

Treatment booked:

Do you have or have ever had any of these conditions?

Give detail as necessary. Have you seen a doctor or other medical professional about these? Are you currently taking any medication?

Are you pregnant? If so please give details including number of weeks, is it first, second pregnancy, any conditions, any issues arising.

GP Name & Surgery:

If medical consent is required, please state name and position of consenting professional

Any current illness, injury, infection, cold or any contagious affliction?

Usual state of health

Any other information you would like to share:

All details remain confidential. By submitting this form you agree that everything relevant has been disclosed.

I agree

You agree to inform Claire's Holistics of any changes to your health during the course of any future treatments, including if you come down with any cold, covid or other contagious illness.

I agree

Massage

Consultation

Massage Consultation

Autumn﻿ 2025 - date tbc - full day training - INDIAN HEAD MASSAGE - BOLTON - click for details

Autumn 2025 - date tbc - full day training - INDIAN HEAD MASSAGE - BOLTON - click for details