Massage Intake Form

Please submit the following form prior to each visit.

Your Name: - Required
Email: - Required
Date of Birth:
Address:
Phone:
Occupation:
Desired appointment:
How long of a session do you want?
Have you ever received massage therapy?
If yes, how often do you get massages?
When was your last one?
Type of massage you prefer:
Do you prefer to start out face up or face down?
On a scale of 1-10, (1 being very light and 10 being very deep)
how would you rate your preference of pressure?
What qualities do you look for in a massage therapist?
What is your intention (goal/expectation) for this massage?
I prefer
Are you interested in assisted stretches?
Would you like to schedule a spa treatment today or in the future?
If yes, which one(s)?

Please list:
I prefer
Are you planning on bringing your own music?
Do you tend to get cold or hot easily?
Each massage includes aromatherapy.
CLICK HERE to choose aromas for this session
 

If yes, please list name & reason for medication:

If yes, please list what kind of therapist and reason/treatment:
If you have (or have had in the past) a condition(s)
that might affect your massage, please list it here:
Do you have any of the following today:
Please explain:
Check the areas you would like me to put more focus on (if any):
Check the areas you would like me to avoid (if any):
If you'd like to add something, please do so here:
  • I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment.
  • This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.
  • I understand there is a draping policy.
  • Being that massage should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully.