Mobile Massage

Mobile Massage Booking Form

Contact Information

Email Address Full Name Phone Number (NZ format) Home Address Emergency Contact Name & Number

Availability

Please describe your availability Preferred Date (Monday to Friday only) Preferred Time (after 3 PM) Select time 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM

Massage Preferences

Type of Massage Reflexology Thai Massage Holistic Massage Preferred Pressure Light Medium Firm Areas to Focus On

Medical History

Massage therapy is not a substitute for medical care. Please provide accurate information for your safety.

I acknowledge and agree Yes No Are you pregnant? Yes No Do you have any medical conditions, injuries, or chronic pain we should know about? Yes No Are you currently taking any medication? Yes No Do you have any allergies to oils, lotions, beeswax, or other massage products? Yes No Have you had any recent surgeries or treatments? Yes No

Payment & Cancellation Policy

Preferred Payment Method Bank Transfer Cash (if agreed upon in advance)

Cancellation Policy: Please provide at least 24 hours' notice for cancellations or rescheduling. Cancellations made within 24 hours will incur a $40 NZD fee. By booking, you acknowledge and accept these terms.

I understand and agree to the payment and cancellation terms Yes No

Terms & Consent

I confirm that I have provided accurate and complete information regarding my health and medical history. I understand the risks involved and consent to the massage treatment selected.

I Agree I Do Not Wish to Proceed

How Did You Hear About Us?

Referral Social Media Website

Photography & Recording Consent

Please note: Any photos or short video clips taken are used ONLY for our social media content to showcase our services. They will NOT include full massage sessions—only small, carefully selected snippets. Your privacy, comfort, and boundaries are our top priority.

I consent and accept 10% discount on my next session I do not consent