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?
60 minutes	75 minutes	90 minutes

Have you ever received massage therapy? Yes No

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?
face up	face down	no preference

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 Full Drape Partial (hand towel)

Are you interested in assisted stretches? Yes No

Would you like to schedule a spa treatment today or in the future?
Yes	No	Maybe in the future
If yes, which one(s)?

I am allergic or sensitive to fragrances or skin care products
such as: Coconut oil, almond oil, scented candles/incense, essential oils, etc.
Please list:

I prefer oil cream no preference

Are you planning on bringing your own music? YES NO

Do you tend to get cold or hot easily? Cold Hot Neither

Each massage includes aromatherapy.
CLICK HERE to choose aromas for this session

I am currently taking medication.
If yes, please list name & reason for medication:

I'm currently seeing a health care professional? (Chiro., Phys. Ther., etc)
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:

	skin rash
	cold/flu
	open cuts
	severe pain

	anything contagious
	injuries/bruises
	ticklish areas

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.

By checking this box, I certify that I am the above named person, that the above information is accurate and that I agree to the above terms and conditions.