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

Health Form to be completed before any Massage Experience 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.

Please be honest when asnswering the questions, so we can keep you, us and our other clients safe.

A telephone consultation may need to 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 Massage complies with our Insurance requirements.

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

First Name & Surname*

This field is mandatory

E-mail

The e-mail address is invalid

Mobile Number*

This field is mandatory

House Number & Full Post Code*

This field is mandatory

Date of Birth*

This field is mandatory

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

This field is mandatory

Are you currently on any medication, list:*

This field is mandatory

Any Allergies, list:*

This field is mandatory

Are you currently in any pain, details:*

This field is mandatory

What are your goals for this treatment:*

This field is mandatory

Type of massage experience required::*

This field is mandatory

Sensual Only - please confirm below that you are in agreement with being massaged intimately: Yes, No or N/A*

This field is mandatory

Do you or have you ever suffered from an infectious illness or sexually transmitted disease? Please state what and when; :*

This field is mandatory

Any body parts not to be touched, i.e. Head, Feet, etc (Very Important):*

This field is mandatory

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

This field is mandatory

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.*

* Indicates required fields

There was an error submitting your message. Please try again.

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

Contact us

Telephone: 07838 267077

E-mail: simplyhandsonuk@gmail.com