Lomilomi Massage ~ Client Intake Form

Your Personal Details

Your preferred name (if different from above)

Your pronouns (optional)

Your best phone number

Date of birth (optional)

Emergency Contact Details

Your Medical & Health Information

Are you taking any medications that may impact me being able to safely massage you?

Do you have any current injuries?

Do you suffer from chronic pain?

Do you have any conditions I need to be aware of to safely massage you? ie cancer, blood clots etc

Do you have any sensitivities or allergies to oils or essential oils?

Do you have any other allergies?

You will be massaged using a blend organic macadamia oil and organic MCT coconut oil. Hot towels with lavender essential oil will be included. A scented face oil will be offered for your face massage.

Normally the following areas of the body are massaged during the massage. If you are NOT comfortable with being massaged/touched in any of these areas, please indicate by clicking on area below. You can change your mind at your appointment.

Please let me know what your goal or intention is for the session. ie relaxation, physical comfort, stress relief, emotional release etc

Is there anything else I need to know to ensure your comfort and safety during your appointment time?

I consent to be emailed post-session information after the massage. I acknowledge this will add me to Kate's mailing list to receive updates of any news, offers and upcoming events. Note: You will be able to unsubscribe at any time.

Yes, I consent to receive post-session information and occasional updates

Consent & Declaration

Please tick EACH statement below to show your agreement before signing.

I declare that the information I have provided on this form is, to the best of my knowledge, true and accurate, and that I have not intentionally withheld any information relevant to my treatment. I will inform Kate Dillon of any changes to my health status.

I understand that massage therapy is for relaxation and therapeutic purposes only. There is no sexual component to the massage. Any inappropriate behaviour will result in the immediate termination of the session and may be reported to the police.

If I experience any pain or discomfort during the session, I will immediately inform Kate Dillon so that the pressure and/or technique may be adjusted to my level of comfort.

I acknowledge that massage therapy is not a substitute for medical care, examination, or diagnosis.

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent to receive treatment.

By booking, I agree to Kate Dillon's Cancellation & Late Arrival Policy: https://katedillon.net/policies/