Massage Intake Form

Please submit an intake form prior to your first visit.

Your Name:

- Required

Email:

- Required

Date of Birth:

Address:

Phone:

Occupation:

How did you hear about Blaizing Lotus?

Desired appointment:

How long of a session do you want?
60 minutes	75 minutes	90 minutes

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

I prefer Full Drape (sheet) Partial Drape (hand towel)

Are you redeeming a gift certificate? Yes No

Will this be your first professional massage? Yes No

If no, are you massaged regularly? Yes No

Are you interested in assisted stretches? Yes No

Would you like to schedule a Spa Treatment today? Yes No

If yes, which one(s)?

	Hot Mint Towels
	Chocolate Mask
	Strawberry/Lemon Mask
	Mineral Heat Lamp
	Dry Skin Brushing

	Seaweed Wrap
	Facial Steamer
	Paraffin Bath
	Sauna
	Mud Wrap

	Sugar Scrub
	Hot Foot Bath
	Rose Package
	Lily Package
	Lotus Package

Type of massage you prefer:

What kind of pressure do you prefer on a scale of 1 to 5?

Musical Preference:

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

I am currently taking medication.
Please list:

I am currently seeing a health care professional.
Please list:

I am pregnant. Months:

Do you have any of the following today:

	skin rash
	cold/flu
	sunburn

	severe pain
	open cuts
	ticklish areas

	injuries/bruises
	anything contagious
	numbness

Please explain, along with any other conditions that may be of concern:

What is your intention (goal/expectation) for this treatment?

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

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:

All massages are draped, following a professional code of conduct and ethics.
Sexual remarks or advances will terminate the session and client liable for payment of the scheduled treatment.
Being that massage should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully.
I will inform my therapist of any changes in my medical status.
I will inform my therapist if I need the pressure to be adjusted, or experience any pain or discomfort during my massage.
I will inform my therapist ahead of time if I have to cancel, or plan on being more than 15 minutes early or late to my scheduled appointment.

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. - Required

~ The ROSE ~

	Swedish Massage aromatherapy body scrub mineral heat lamp dry skin brushing
($100 for 60 minute massage and $120 for 90 minute massage)

~ The LILY ~

	Deep Tissue Massage aromatherapy hot peppermint towels body scrub mud wrap or seaweed wrap paraffin bath chocolate facial mask
($150 for 60 minute massage and $170 for 90 minute massage)

~ The LOTUS ~

	Hot Stones Massage aromatherapy body scrub mud wrap or seaweed wrap paraffin bath chocolate facial mask facial steamer foot bath far infrared sauna
($200 for 60 minute massage and $220 for 90 minute massage.)