Massage Form Massage Form 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) Select OneGooglebingFacebookYahooMSNLocal HotelDrove byReferred by a FriendReferred by an EmployeeCoupon 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) Security Code Enter security code. Thank you for filling out the massage form. This will save you time when you come in!