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Booking

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Personal Details - Step 1 of 2

Your Name *

Address *

Phone number *

Email Address *

If you need an appointment for someone under 18, please provide your own contact details.

Date of Birth

Occupation

Are you currently on medication?

What is the name of the medication?

Gender

This allows us to ask appropriate questions about you.

Lifestyle

Sendentary
Active

Date of your last period

Medical history (Diagnosed by a doctor)

Please indicate if you have any medical history e.g, Ulcer, Depression, Anxiety, etc.

Any Medical Oedema?

Do you have arthritis

Any condition currently treated by a GP?

Did you experience any fever in the last 24hours?

Are you alcoholic?

Do you have any infections/Contagious disease?

Do you have any skin disease?

Is there any undiagnosed Lumps/bumps?

Are you always under the influence of Alcohol/Drugs

Do you have any Inflammation/Swelling

Do you have any Bruises

Please indicate if you are in any of these situation

Gastric ulcers
Peptic ulcers
Loss of skin sensation
Varicose veins
Pacemakers
Breastfeeding
Open wounds
Acne

Do you have any metal plates or pins

Gender Do any

Do you have any conditions affecting the neck

Please indicate if you are in any of these situation

Hormonal implants
Pregnancy
Hernia
Recent operations
Menstruation
Back pain
Stiff joints
Headaches

Do you experience Aches and/or pain (where, please indicate)

If none, please indicate NO

Sleeping pattern (How long do you sleep in hours)?

Are you taking any supplement?

Please indicate the supplement

Any suffering from food allergies?

Please indicate the food allergies

Please indicate stress level at home

Stress Level: 0

Please indicate stress level at work

Stress Level: 0

Choose your preferred treatment method

Stimulating
Invigorating
Soothing
Relaxing
Uplifting
Sense of well-being
Anti_cellulite
Use of infrared

I acknowlege *

I understand that I have the Body massage Treatment at my own risk and accept treatment as such. I also confirm that the above statements are true, knowing that you are relying upon them in the course of the treatment of my condition. I also accept that I will be undergoing a treatment by a professional and hereby wave my rights to any legal action in this regard.

Contact us

Road 20 Sars road portharcourt (landmark: Limburge hotel signage)
0704 311 8846
07086520224
0902 482 7413
0816 379 7083
Oyemenjaphet@gmail.com

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