Massage Form | MADA Clinic and Spa

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Nr 1 KLINIKA SKÓRY

SMITHFIELD, DUBLIN!

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Formularz masażu leczniczego

Prosimy o poświęcenie chwili na wypełnienie formularza.

First Name

Last Name

Email

Birthday

Phone

Please list any medications, supplements or herbal remedies you currently take:

Please list any allergies or sensitivities:

Please list any injuries or surgeries:

Do you have a history of cancer? If yes, please specify:

Please check all that apply:

Pregnant

Postpartum

Neck pain

Back pain

Headaches

Diabetes

Seizures

Knee / Leg pain

Jaw pain / clenching / grinding

Metal implants

Fibromyalgia

Used Retin-A within the past 10 days

None of the above

What is your goal for this session?

I acknowledge that all information I provided in this form is true and accurate.

I understand and agree to maintain respectful communication with the massage therapist, both verbally and non-verbally. I will communicate any discomfort and provide explicit consent before any massage technique or adjustment of body positioning. I acknowledge the zero-tolerance policy for harassment and understand that any violation may result in immediate termination of the session and potential prohibition from future appointments. I understand that the anti-harassment policy may be reviewed and updated periodically for the safety and well-being of all clients.

Date of signing

Your Signature

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Enter your email here

Thanks for submitting!

Jesteśmy otwarci

Wtorek-czwartek: 11:00-19:00

Piątek: 12:00 - 20:00
Sobota: 10:00-16:00

Adres: Jednostka 2, Block E, Thundercut Alley, Queen St, Smithfield, Dublin 7, Irlandia

Obsługa klienta

E-mail: info@madaclinicspa.com

Telefon: 01 575 9865

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