Facial Massage/Reflexology Client Form

This form will give me the information needed prior to your appointment to ensure you are able to have the service you booked.
If your unsure about any part of the form, we can fill it out in clinic.

Please enter persons name and contact number
Please note what work you have had done, when it was done and the recovery time for the work.
(If no skip questions with a *)
1 = No pain at all and 10 = Worst pain I've ever experienced
Statement of Consent: I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension and conditions suitable for treatment using soft tissue therapies. If I experience any pain during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I confirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. I acknowledge that should I be late for my appointment the therapist has the right to alter the length of my massage to suit the needs of the office schedule.
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