Consultation Form – Vital Massage Therapy

Consultation Form
Please complete this even if you’re a returning customer

COVID-19 Notice

Once you submit this form, you’ll automatically redirected to our COVID-19 Questionnaire. This needs to be completed no sooner than 24 hours before your appointment. If you’re appointment is more than 24 hours away, you can access this form via our COVID-19 page which you’ll find under ‘About’.

Name *

Date Of Birth *

Address *

Telephone Number *

E-Mail Address *

Doctor’s Name & Address *

Do you suffer from diabetes? *

Do you, or have you ever, suffered from a heart condition? *

Do you, or have you ever, suffered from cancer? *

Do you, or have you ever, suffered from varicose veins? *

Do you, or have you ever, suffered from asthma? *

Do you currently suffer from epilepsy? *

Do you, or have you ever, suffered from any joint conditions? *

Are you currently suffering from any infections, allergies, fevers or high temperatures? *

Are you pregnant? *

Are you currently taking any medication? *

If yes, please specify

Have you had any operations in the last 18 months? *

Reason for massage: *

Have you had any previous massage treatments? *

How did you hear about us? *

Anything else you think we might need to know...

Please confirm that you are happy for your personal details to be shared with NHS Test and Trace and Public Health England should the need arise. *

GET IN TOUCH

07810 301198
info@vitalmassagetherapy.co.uk