Consultation Form for Remedial Session

Filling out this form ahead of time ensures we can get right to your massage when you arrive. This allows your therapist to be fully prepared and for you to get the most out of your scheduled session. If you need to complete the form at your appointment, please note that it will take time away from your treatment.

First Name

Last Name

Preferred Name

Birthday

Day

Month

Year

Email

Phone

Address

Country/Region

Address

City

Zip / Postal code

Health info

Have you had a massage before?

Yes

No

Have you had any operations/injuries (past or present please specify)

Why this matters: Your body's history tells a story. Things like scar tissue and fascial restrictions can build up at the site of an old injury, which might be contributing to pain or discomfort you're feeling now. By knowing this, we can give you a more effective and valuable treatment.

What do you do for work?

This gives us a a better idea of how you use and move your body from day to day.

What do you enjoy doing in your free time (exercise and activities)

How do you use/move your body in your free time?

Areas of tension/pain you are experiencing (past and present helps)

Fun Fact: Have you ever noticed? Sometimes when we get unwell or experiencing high moments of stress, old pain patterns can show up, like that nagging backache or a dull shoulder ache. This is because even after an injury has healed, the nervous system can remain on high alert in that area and sends "danger" signals to your brain even when there's no threat.

Any other additional information you would like to share, please write it here:

Health Details

Please provide further details if you ticked any of the boxes above

Areas you want to avoid in the session?

Note for Remedial Sessions: In a remedial session, we utilize a variety of techniques and tools, such as cupping and dry needling, tailored to address your specific needs. Please note they are not always necessary during the session and it will always be discussed before or during the session. Our bodies are constantly adapting to daily stresses and challenges, and while we may not always need these tools, having them in our toolkit ensures we can address your needs effectively when necessary. This approach means you receive the best possible results, without the need to book multiple treatments.

Please ensure you have read the details before your treatment begins. www.chiasplacemassage.com/remedial-massage

Please provide your consent to use massage, dry needling, and cupping techniques during your sessions:

Yes

Signature

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Treatment and Disclaimer

By signing and submitting this form, you acknowledge that:

The therapist reserves the right to withhold or modify a treatment if it is deemed unsuitable or potentially harmful to your health.
You understand the benefits, potential side effects and prohibitions associated with each treatment