Wellness with Majella Consultation Form

Mobile-friendly intake form for safe treatment planning and insurance documentation.

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Personal Information

Name *

Phone *

Address

City

Post code

DOB

Occupation

Email *

GP address

GP name

Emergency Contact

Relationship

Emergency Phone

How did you hear about us?

Medical Information

Please indicate any of the following that apply to you.

CancerFibromyalgiaHeadaches/MigrainesStrokeArthritisHeart AttackDiabetes 1Kidney DysfunctionJoint Replacement(s)Blood ClotsHigh/Low Blood PressureNumbnessNeuropathySprains or Strains

If yes, how far along?

Are they controlled by medication?

Do you suffer from chronic pain?

YesNo

If yes, please explain

Have you had any recent surgeries?

YesNo

If yes, please list

Massage Information

Have you had a professional massage before?

YesNo

How long ago?

Do you have any allergies or sensitivities?

YesNo

Please explain

Are there any areas you do not want massaged?

YesNo

Please explain

Consent

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

I confirm and consent to this statement. *

Client signature (typed name) *

Client signature date

Therapist signature (optional)

Therapist signature date

Form data is securely saved for treatment planning and can be reused during booking.

Wellness With Majella

Holistic wellness through yoga, energy healing, and reflexology.

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