Consultation Form for Remedial Session

To ensure I provide you with the best possible care, it’s important that you answer the following questions as thoroughly as possible. The more detailed your responses, the more I can tailor your treatment to suit your individual needs.

Please remember, injuries or surgeries from years ago can still impact your body today due to scar tissue and compensation patterns. The body is incredibly adaptable, and while it learns to function under the circumstances it's faced with, this doesn't mean you have to continue living in pain. I am here to help you find relief and improve your quality of life.

First Name

Last Name

Preferred Name

Email

Phone

Address

Country/Region

Address

City

Zip / Postal code

About You

Have you had a massage before?

Yes

No

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

What do you do for work?

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

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

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 to avoid in the massage session?

In a remedial session, we utilise a variety of techniques and tools, such as cupping and dry needling, tailored to address your specific needs. 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

Signature field is empty.

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