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Consultation Form

Pre-treatment Consult Form

Please fill out the following form
in order to receive your Massage Treatment. 

Any and all information follows strict GDPR guidelines, is protected & stored safely.

Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?
Have you undergone an operation or will you be undergoing surgery within the previous/next 2 months? Are you or do you plan to undergo medical tests?
Which would be your preferred treatment/service?



Do you or have you ever suffered from:


Cellulitis, Contagious Disease, Imminent Medical Tests, Thrombosis/DVT, Phlebitis, Aneurism, Severe Undiagnosed Headaches, Undiagnosed Illness, Stroke, Gangrene, Cut/dead nerve conditions/damage of Neuropathy, Diabetes, Skin conditions worsened by massage or heat, Pregnancy (first trimester or if history of miscarriage, no abdomen massage at any time, post birth up to 3 months) Prescription medications sensitive to heat or massage stimulation, Heart Disease, Varicose Veins, Immunity diseases whilst undergoing treatment, Elderly or young children sensitive to heat of stones, Inflamed organs, Cancer, Cancer’s of bone and Hodgkin’s disease, Within 6 months of radiotherapy, chemotherapy or surgical operation, Cardiovascular issues, Inflammatory conditions, Epilepsy, Mental disorder, Diagnosed Depression.

Localised Contra-indications (massage to avoid these areas)


Recent fractures, cuts, open wounds, broken skin, abrasions, burns, recent scar tissue, severe varicose veins, contraceptive implant, pacemaker, suspected or real thrombosis, acute rheumatoid arthritis, undiagnosed lumps.

I do not suffer from any medical problems other than the ones listed on this form. I agree to undertake the treatment and I will seek medical approval from my GP should the situation with my health change. I understand that my therapist is qualified in the services advertised. I understand that my therapist is covered with public liability insurance as well as Therapy Insurance and a member of relevant associated bodies.

Should I become positive with COVID-19 prior to our appointment, I will re-arrange when I can confirm clear and negative results. I understand Sam operates a 48 hour cancellation policy and I will adhere to this to the best of my ability. 

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