Personal Information

First name

Last name

Birthday

Day

Month

Year

Phone

Email

Emergency Contact Name

Emergency Contact Phone Number

Health Information

Do you have any medical conditions or diagnoses that I should be aware of?

Are you currently taking any medication?

Do you have any allergies?

Safety Screening

Are you currently pregnant?

Yes

No

Have you had surgery or any serious injury within the last 12 months?

Yes

No

If Yes: Please provide details

Current Condition

Are you currently experiencing any pain, discomfort, or restricted movement?

Please indicate any areas you would like me to avoid during your treatment.

Treatment Goals

Consent

I confirm that the information provided is accurate and complete to the best of my knowledge.

Required.

Treatment Adaptation and Safety I understand that if the therapist identifies any signs or conditions that may affect the safety of the treatment, the treatment may be modified, certain areas avoided, or the treatment discontinued for my safety.

I have read, understood and agree to the above.

I consent to receiving massage or body treatment and understand that I can withdraw my consent at any time.

Required.

I have read and agree to the NK Wellness Studio Cancellation Policy. I understand that appointments cancelled or rescheduled with less than 24 hours’ notice will be charged in full.

Required.