Massage Screening Form

Not sure what type of massage you need?
Please complete the form below and I will be able to contact you to discuss your treatment.

What type of treatment do you require?

Relax - relaxation, time out to chill and have your stresses eased away. Remedy - remedial massage with a defined outcome required. For issues in the tissues, pain management, mobilisation.

Are you looking for a one off treatment or ongoing treatments?

On-off On-going

Reason for treatment. Please be as specific as possible e.g. relaxation, headaches, stress relief, frozen shoulder, lower back pain etc

If you would like treatment for a condition, has it been diagnosed and when? e.g. Osteoarthritis - GP by MRI scan, 7/2018

Have you seen another practitioner for this condition? e.g. osteopath, physiotherapist etc. If yes, did you have a treatment plan? Did it work and what changed? Please detail

I give Jemma of Relax & Remedy permission to contact me to further discuss or book a treatment

Phone call Email

Massage Screening Form

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