Intake & Health Screening

Massage Intake Form

Please complete this before your first massage. It tells us where to focus, what to avoid, and anything we need to adapt for.

How your information is used. Evergreen Essence collects these details only to assess whether a treatment is safe and suitable for you, and to keep a record of your care. They are not sold or shared, and are kept only as long as needed. To see, correct or delete your information, email evergreenessencespa@gmail.com.

About you

 Step 1
Street, city and postal code.

Your appointment

 Step 2

Health screening

 Step 3

Some of these genuinely change what we can do safely. Answering yes usually means adapting the treatment rather than cancelling it.

  • Do you have — or have you ever had — a blood clot, DVT, or a pulmonary embolism?
  • Are you pregnant?
  • Do you have heart failure, kidney disease, or uncontrolled high blood pressure?
  • Are you currently having treatment for cancer, or have you had it in the past?
  • Do you have lymphedema, or have you had lymph nodes removed?
  • Have you had surgery in the last 12 months?
  • Do you currently have a fever, infection, or feel unwell?
  • Do you have any rash, open wound, burn, or contagious skin condition?
  • Are you taking blood thinners, or do you bruise very easily?
  • Do you have osteoporosis, or any recent fracture or injury?
  • Do you have varicose veins?
  • Do you have any allergies to oils, lotions or nuts?Almond oil is very common in massage products.
  • Do you have any other medical condition, or are you under a doctor's care?

Anything else we should know

 Step 4
Please list anything you answered yes to above.

What I understand

 Step 5

Your signature

 Final step
By typing your full legal name below you are signing this form electronically. This carries the same weight as a handwritten signature.

A copy goes straight to Evergreen Essence. Nothing is shown publicly.

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