Francy Women Wellness | Tailored Mobile Massage for Women

Consultation Questionnaire

First

Last name

Full adress

E-mail adress

Mobile number

Date of birth

Day

Month

Year

Medical history

Have you ever received a medical diagnosis for a significant health condition?

Yes

No

Are you currently taking any medications?

Yes

No

Are you currently pregnant or within 12 months postpartum?

Yes

No

If yes, please specify how many weeks/months pregnant you are or how long ago you gave birth ?

Is there anything else you would like to share about your health, comfort, or massage goals?

Do you have any allergies including fragrances, lotions, latex or oils? if yes, please specify

yes

no

By proceeding with this booking, I confirm that I am a female client and acknowledge that this is a female-only service. Bookings made by male clients will be cancelled. I also confirm that all information provided is true and accurate. Signature :

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