Rossell Fitness Massage Consultation

Name*

First Last

Age*

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email*

Phone number*

Have you had a DEEP TISSUE or SPORTS massage before?*

Yes
No

Did you experience any bruising following your last deep tissue massage?*

Yes
No
N/A

Please describe in your own words your lifestyle including your dietary habits for example typical working hours, any sports or training that you do and whether you consider yourself to be a healthy eater?*

Medical history (check all that apply)*

Please expand on any condition that you ticked a box for above. This is for your health and safety and is imperative. [If you ticked 'none of the above', please just type NONE]*

Please state any medications that you are taking and the reason for taking this medicine*

Please tick the areas of your body that you wish me to focus upon in your massage session(s) (please understand that there is a limit to what can be achieved in 1x30min or 1x60min session)*

I run ladies group training sessions where we build confidence, fitness and strength in sessions designed to help you take the control back over your weight and health! Are you interested in learning more about getting fitter, healthier and building your confidence in your lifestyle choices?*

Yes
No

I understand that I may experience side effects to deep tissue massage including but not limited to (bruising, stiffness, soreness of any kind, congestion, dizziness, fatigue, confusion, dehydration, build up of toxins, nausea) and I accept that these can be normal side effects of a treatment.*

Yes
No

You will be sent a copy of Rossell Fitness Massage aftercare information to give you the correct and safe guidance that you need to get the best out of your treatment!

I confirm that the above information is correct to the best of my knowledge. I understand what I am undertaking with a deep tissue massage and give my consent to the treatment and to be contacted by Rossell Fitness. I understand that there is a limit to what can be achieved in one session of deep tissue massage and accept that I may have to consider further treatment. I am happy to accept rehabilitation guidance from my massage practitioner and accept that the effectiveness of the massage and subsequent satisfaction is determined by how I choose to act in the hours/days following the treatment. I give my consent to be contacted using the information I've provided in this questionnaire*

I confirm

Thanks for filling in my form and I will be in touch very soon! I recognise that I am freely giving my contact details to Rossell Fitness, and that my details WILL be used to contact me regarding my request and other related services. I give my full consent for this.Your data will be protected and never shared with third-party companies. In accordance with GDPR regulations, you are entitled to request to see what information is held about you, opt out of any communication at any time and change any information we hold. We will comply with your request within the designated time frame.