Initial Client Consultation Form

Personal Details

First name*

Last name*

Email*

Phone*

Birthday*

Day

Month

Year

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Additional Information

Emergency contact details

Did your GP or Health Consultant recommend you to have a Massage Treatment?*

Yes

Do you have any medical conditions that might be impacted by a Massage Treatment?*

Yes

Do you have any allergies?*

Yes

Do you have any recent operations or injuries?*

Yes

Are you pregnant or recently gave birth?*

Yes

Are you taking any medications that can either impact a Massage Treatment or can be impacted by a Massage Treatment?*

Yes

Is there any other reason why your Massage Treatment might have to be restricted or avoided?*

Yes

If you have answered Yes to any of the questions above, please provide further details.

How did you hear about Palmarys?*

Would you like to join our mailing list for updates on offers and services? Your details won’t be shared. If you select No, you’ll still receive appointment reminders and notifications.*

Yes

Informed Consent and Disclaimer

I understand that while massage treatments at Palmarys are generally beneficial, some may be unsuitable for certain conditions. I confirm I’ve disclosed all relevant health information and will update the therapist of any changes. I acknowledge it’s my responsibility to seek medical advice if needed, and if I choose to proceed without it, I do so at my own risk. I consent to treatment and release Palmarys, the therapist and the venue from liability for any resulting issues.

Date*

Day

Month

Year

Signature / Full Name*

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Please type your full name instead of a signature to confirm that all information provided is accurate and that you have read and agree to the consent statement above.

Your personal and health information is collected securely and used only to provide your treatment and manage appointments. It will never be shared with third parties.

Forms

Palmarys

07543 457 233 | palmarys@outlook.com

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