Deep Tissue Massage Consultation

Name*

First Last

Address

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

Age*

Email*

Phone number*

Groupon 10 digit security code*

This code usually has a combination of letters and numbers for example AB12345678.

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)*

As part of a healthy lifestyle, I work with ladies on their health, happiness and confidence. I mainly do this via ladies only courses where we exercise in the gym and work on nutrition, sleep, stress and lifestyle management. The courses have been incredibly successful at helping ladies in Leicester to lose weight and improve their energy, health and body confidence. Do you wish to be informed about my upcoming ladies only 12 week transformation programmes?*

Yes
No

For more information right now you can visit this webpage: https://www.rossellfitness.co.uk/transformation

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. 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 am happy for my email address to be used to contact me with relevant information regarding deep tissue massage.*

I confirm

Thanks for taking the time to fill this in, I will be in touch if necessary! Your GROUPON booking email will act as your booking reference however please note that you will be expected to show your voucher to your masseuse on the day of the massage. If you have already booked your appointment please note that cancellations should be given with at least 48 hours notice

Rossell Fitness Deep Tissue Massage Consultation