Sports Massage & Natural Face Lift Treatment Questionnaire...

Name *

First

Last

Email *

Phone Number *

D.O.B

Address:

How did you hear about LEP Fitness?

What is your reason for wanting a massage? Please provide as much detail as possible...

Occupation:

In case of an emergency contact: Name:

In case of an emergency contact: Contact number:

GP Details: Name, Surgery, Address, Contact Number:

Do you have, or have you had in the past 6 months, any of the following listed below: Please tick relevant boxes...

I fully understand that thorough and honest responses to these questions are essential to my safety. I herby confirm that the information stated above is accurate to the best of my ability and I undertake to inform my practitioner of any changes.

I further understand that prior to any treatment a physical assessment needs to be carried out. Please confirm that you are happy to proceed by ticking the box below.

Yes
No

Sports Massage & Natural Face Lift Treatment Questionnaire…