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Home
Our Services
Gallery
FAQ
Blog
Our Experts
Prices
Contact Us

Home
Our Services
Gallery
FAQ
Blog
Our Experts
Prices
Contact Us

Home
Our Services
Gallery
FAQ
Blog
Our Experts
Prices
Contact Us

71 Vyse street, Jewellery Quarter, B18 6EX

Tel: 01213893005

MASSAGE CONSENT FORM

Home Massage Consent Form

Massage therapist form

Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

G.P. Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

G.P. Phone(Required)

Emergency contact(Required)

First Last

Phone(Required)

Relationship(Required)

Are you currently taking medication: if yes, please list these below(Required)

Are you pregnant?(Required)

Do you suffer from chronic pain?(Required)

Have you had any orthopedic injuries?(Required)

Do you suffer from epilepsy or seizures?(Required)

Do you suffer from joint swelling?(Required)

Do you have any contagious diseases?(Required)

Do you have osteoporosis?(Required)

Do you bruise easily?(Required)

Have you been in an accident or suffered any injuries in the past two years?(Required)

Do you have tension or soreness in a specific area?(Required)

Do you have cardiac or circulatory problems?(Required)

Do you suffer from back pain?(Required)

Do you have numbness or stabbing pains anywhere?(Required)

Have you ever had surgery?(Required)

Do you suffer with any of the following:(Required)

Cancer

Headaches/Migraines

Arthritis

Diabetes

Joint Replacement(s)

High/Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Sprains or Strains

None of the above

Have you had a professional massage before?(Required)

Are you sensitive to touch or pressure on any area of your body?(Required)

What type of massage are you seeking?(Required)

Relaxation

Deep Tissue massage

Don't know

What pressure do you prefer?(Required)

Light

Medium

Deep

Don't know

Are there any areas (feet, face, abdomen, etc.) you do not want massaged?(Required)

Informed Consent(Required)

I acknowledge that the massage therapy I am about to receive is primarily intended to relieve muscular tension and promote relaxation. If I experience any discomfort, I will inform the therapist immediately so that they can adjust the pressure and strokes accordingly. I understand that massage is not a substitute for medical diagnosis, examination, or treatment, and if I have any health issues, I should consult a qualified medical professional.

I affirm that I have disclosed all known medical conditions and provided honest answers to all questions. I understand that massage therapists are not authorized to diagnose, prescribe, or treat mental or physical illnesses, nor perform skeletal or spinal adjustments. If there are any changes to my medical profile, I will inform the therapist.

I acknowledge that if I arrive late for my appointment, the therapist may need to adjust the massage's duration to accommodate the schedule. I understand that any inappropriate behavior, remarks, or advances on my part will result in immediate termination of the session, and I will be responsible for paying the scheduled appointment fee.

I agree to the above statement of consent

Comments

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Disclaimer: Results may vary from person to person and treatment to treatment.

01213893005
info@theglamfairies.co.uk
71 Vyse street, Jewellery Quarter, Birmingham, B18 6EX

The Glam Fairies in Birmingham is your go-to destination for a variety of aesthetic treatments. We offer top-notch services like microneedling, which stimulates collagen production and allows anti-aging serums to penetrate deeper into the skin for improved health and integrity. Our chemical peels use pharmaceutical-grade ingredients to promote new skin cell growth, resulting in a fresher and brighter complexion. Our clinic provides skin boosters and Profhilo, an industry standard for skin rejuvenation. For those seeking a more advanced treatment, PRP microneedling uses platelet-rich plasma to help repair skin tissue and reduce signs of ageing. And to complement these procedures, we offer Botox for a smoother, youthful appearance.