Name: Simply Hands On Massage
Address: 245 North Street, Mansfield, Nottinghamshire
Telephone: 07838 267077

Health Questionnaire to be completed before any Treatment or Massage Service is provided

Please answer every question on the form

These questions are fully confidential and will enable your therapist to ensure you receive the massage that best suits your physical and mental needs.

A telephone consultation will take place between you and the therapist to discuss the form further, answer your questions and finalise your appointment.

Thank you for taking the time to complete this form, which is a safety requirement and to ensure Simply Hands on complies with our Insurance requirements.

Feel free to email via this link if you have any questions that you would like answering first.

Full Name*

This field is mandatory

E-mail

The e-mail address is invalid

Mobile Number

Full Address and Post Code

Date of Birth

Have you ever had any of the following, Arthritis, Diabetes, Fibromyalgia, Blood Clots, Heart Issues, Stroke, Joints replaced, other major illness or surgery, list:

Any Allergies, list:

Are you currently on any medication, list:

Are you currently in any pain, details:

What are your goals for this treatment:

Type of massage required (see Services & Prices):

Pressure required (Light, Firm, Mix):

Any body parts not to be touched, i.e. Touch Any or List the Specific Do Not Touch Areas (Very Important):

Lomi Lomi (if chosen) is a full body massage best performed on a nude or scantily clad body, are you OK with this and understand that all body parts will be massaged, unless listed above: Yes or No

Where did you hear about us, Facebook, TikTok, Instagram, Google, H&E, X or other (please state):

I hereby agree that this data will be stored and processed for the purpose of establishing contact. I am aware that I can revoke my consent at any time.*

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Thank you! We will get back to you as soon as possible.

Contact us

Telephone: 07838 267077

E-mail: simplyhandsonuk@gmail.com

Mobile Massage in Nottinghamshire, Derbyshire and South Yorkshire