CONSULTATION FORM

SKIN ANALYSIS

NAME:__________________________________________________________DATE:____________________
TEL NUM:______________________________IC NUM:__________________________AGE:__________
OCCUPATION:_________________________________ BEAUTICIAN:___________________________
SERVICE : _________________________ START TIME:____________FINISH TIME:____________

Massage Information
Have you ever had a professional massage before? Yes No
If yes , how often do you receive massage
therapy?______________________________
If yes , do you have a style or pressure preference? Yes No

Specify: Light pressure Medium pressure Deep pressure

Trigger Point Therapy Energywork

Other____________________________________________

What Type of massage are you seeking for today?

Relaxation Deep Tissue/Therapeutic Pregnency

Intergrated Bodywork (Functional) Other________________________

Are you sensitive to fragrance or perfumes? Yes No

Do you have sensitive skin? Yes No

Do you wear contact lens? Yes No

What are you common areas of Pain or Tension?

Circle any specific areas you would like the massage therapist to
concentrate on during session:
EFFECTS/BENEFITS

Aftercare Advice Comments

Homecare Advice

Future Treatments
needs

Product
recommendations

Possible reaction

24hr following
-no heat

12 hours following
- Avoid makeup.

12 following
-Increase water
intake.

12 hours following
-Avoid touching
area.

12 hours following
- Rest
Client comments:

Client Signature:

Learner Comments:
Were you happy with the service you have carried out? YES /NO
What can improve on next time?

Learner Signature:

Tutor / Assessor comments:

Was any part of the service carried out a competent assessment? Yes/NO

Tutor/Assessor name & Signature:

 DISCLAIMER

CLIENT INFORMATION

Please read carefully and only sign if you are in full agreement with its contents.
I…………………………………………………………Confirm that I have understood the
treatment that I am to receive and confirm that I am willing to proceed without
confirmation from my own GP or Consultant.

You should note that the student/therapist is unable to explain to you the
indications or is unsure of anything that may apply to a specific condition then
should not treat you without asking you to consult with your GP or Consultant.

It is your responsibility and not the student/consultant to consult your GP or

Consultant.
I hereby to identify the student/therapist against any adverse reaction sustained
as a result treatment.

Clienr Signature:………………………………. Date:……………………………………….

Student/Therapist:…………………………… Date:………………………………………