Massage Form

Massage Form

Portrait of an attractive young couple lying on massage bed at spa
Portrait of an attractive young couple lying on massage bed at spa

First Name (required)

Last Name (required)

Phone Number (required)

Your Email (required)

How did you hear about us? (required)

Have you received a massage before? (required)
YesNo

If "yes" how often?

What is the reason for your massage?

Are there any areas you want me to concentrate on? (required)

Do you prefer a deep or a light massage?

Are there areas you want to avoid being treated?

Are you under the care of a physician or health care practitioner? (required)
YesNo

If "yes" is indicated, for what?

Are you having any problems we should know about? (required)

Current Conditions:
PregnancyHeadachesSleep DisturbancesInflammationFatigue
Blood ClotsAsthmaEasy BruisingCancerSkin problemsDizziness
High/Low Blood PressureHeart ProblemsNumbness/TinglingVaricose Veins
Hernia/UlcerDiabetesDigestive ProblemsBreathing Problems

Please list any medication you are taking:

Notes!

I understand the massage services are designed to be a health aid and are in no way to take the place of a doctor's care when it is indicated. Information exchanged during any massage session is educational in nature and is intended to help you become more familiar and conscious of your own health status and is to be used at your own discretion.

Emergency Contact (name, phone & relationship): (required)

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