Treatment Intake Form

Metatron’s Cube contains all shapes within itself

Please fill out all information as accurately and thoroughly as possible.

Name(required)

Email(required)

Address(required)

Contact Number(required)

Occupation(required)

DOB(required)

Emergency Contact(required)

Relationship(required)

Treatment: (Swedish, Aromatherapy, Reflexology, Hot Stone, Indian Head, Reiki)

Treatment Type: Relaxing, Uplifting, Stimulating, Immune Boosting, Detoxifying

Target / Problem Areas:

Areas to avoid:

Health Status

Are you currently experiencing or have you ever had any of the following conditions: (Please enter Yes / No)

Heart Conditions(required)

Epilepsy(required)

Contagious Disease(required)

Diabetes(required)

Cancer(required)

Carrier of HIV / Hepatitis(required)

Severe Circulatory Disorders(required)

History of Thrombosis / Embolism(required)

High / Low Blood Pressure(required)

Dysfunction of Nervous System(required)

Recent Hemorrhage or Swellings(required)

Allergies(required)

Recent Scar Tissue(required)

Loss of tactile Sensation(required)

Are you Menstruating or Pregnant?(required)

Cuts / Abrasions(required)

Recent Operations(required)

Recent Fractures or Sprains(required)

Metal Plates or Pins(required)

Electronic Implants(required)

Fever(required)

Skin Disorders / Conditions / Bruising(required)

Varicose Veins(required)

Recent Surgery?(required)

Warts or Moles?(required)

Any further information to add?

DECLARATION AND INFORMED CONSENT TO MASSAGE THERAPY TREATMENT

I confirm that the above information is true and accurate to the best of my knowledge. I have been given the opportunity to ask all the questions about its content, and all of my questions have been answered to my satisfaction. I appreciate that although all reasonable steps have been taken, including screening potential, and undertaking increased hygiene and distancing protocols there still may be a risk of infection from Covid – 19. I knowingly and willingly consent for a face to face appointment to take place.

Signed:(required)

Date:(required)

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