Room1, 64 Bethel street,Norwich, NR2 1NR 07821501516 Opening Hours:Mon – Sat: 09:00- 17:email@example.com Services Sports massageSwedish massageHot stone massageIndian head massageDeep tissue massageCouples Lush massageCouples VIP massageMassage Gift VouchersAromatherapy massageThai yoga massageFoot massageChair massageFacial massageTrigger point therapyFour hands massagewaxingBaby massage About usOur pricesBook AppointmentContact UsMembershipLog In Appointments Ready for your next relaxation experience? Please book an appointment 1. Your Details 2. Intake Questionnaire 3. Confirmation Company FIRST NAME EMAIL ADDRESS ADDRESS LINE 1 CITY COUNTRY YOUR OCCUPATION EMERGENCY CONTACT NAME Choose Service Choose Service Sports massage Swidish massage Hot stone massage Indian head massage Deep tissue massage Aromatherapy massage Thai Yoga Massage Foot Massage Chair Massage Facial Massage Trigger Point Therapy Four Hands Massage Waxing Couples Lush Massage Couples VIP Massage Massage Gift Vouchers Baby Massage Choose Date LAST NAME PHONE NUMBER ADDRESS LINE 2 COUNTY POST CODE DATE OF BIRTH EMERGENCY CONTACT NUMBER Session Duration Session Duration 20min 30min 1hour 2hours Choose Time Choose Time 9am 10am 11am 12noon 1pm 2pm 3pm 4pm Are you taking any medications? * Yes No Are you currently pregnant? * Yes No If yes, please provide details If yes, how far along? Any high risk factors? Give details Do you have any allergies or sensitivities? * Yes No If yes, please provide details Have you had any recent injuries? * Yes No If yes, please provide details Please indicate if any of the following apply to you Cancer Fibromyalgia Arthritis Stroke Headaches / Migraines Heart Attack Please also indicate if any of the following apply to you Diabetes Blood clots Joint Replacement Kidney Dysfunction High/Low Blood Pressure Numbness Neuropathy Strains or Sprains Explain any conditions you have marked above Have you had a massage therapy before? * Yes No What are your goals for this session? By ticking this box, I agree that i have completed this form to the best of my knowledge and agree to inform my therapist if any of the above information changes at any time.