info@makemovements.co.uk
Mobile Massage Service
7am - 11pm
Mr / Mrs / Miss / Mrs (required)
First Name (required)
Surname (required)
Date of birth - dd/mm/yyyy (required)
Contact Number (required)
Email Address (required)
Home Address (required)
Address for massage treatment (required)
Male / Female / Other (required)
Name (required)
Contact number (required)
Surgery address (required)
Relationship (required)
Do you have, or have you had in the past 6 months, any of the following symptoms/conditions?
OBSERVABLE CONTRAINDICATIONS: Skin disorders (Eczema)FeverRecent OperationsInflammationSprains and StrainsCutsBruisesBurnsFracturesInfection (Septicaemia)BursitisVaricose VeinsSwelling (required)
GP CONTRAINDICATIONS: CancerCardiovascular Disease (Heart)Undiagnosed LumpsEpilepsyNervous System DisordersLymphatic System DisordersAutoimmune Disorders (HIV and AIDS)High/Low Blood PressurePneumoniaThrombosis (DVT) (required)
PERCAUTIONARY CONDITIONS: Medically Weak SkinBone, TissuesHaemophiliaPregnancyUndiagnosed Musculoskeletal Disorders / Asthma / AllergiesHeadachesSinusitisDiabetesSubstance Addiction
Additional Details: If you answered YES to any of the previous questions, please provide further details below.
If required, has permission been given by the GP/Consultant to carry out the treatment (please bring the letter to your first treatment) NoYesNot Required
Have you visited your GP in the last 6 months? (required) NoYes
Are you on any prescribed medication? (required) NoYes
Are you receiving treatment from another healthcare professional? (required) NoYes
I hereby confirm that the information stated above is accurate to the best of my ability. I further fully understand that thorough and honest responses to these questions are essential to my safety. I undertake to inform my therapist of any changes to the above information (required). I AGREE
I understand that an assessment needs to take place in order to establish a treatment plan. All assessment and treatment procedures have been thoroughly explained and I am happy to proceed (required). I AGREE
Date - dd/mm/yyyy (required)
Client Signature (required):
Please make sure all the required fields are filled out before submitting this form otherwise it will not send.