Form | Contact & Service Request Page

Personal Information

Name

Address

City

Postal Code

Occupation

Email

Phone

DOB

Emergency Contact

Relationship

Phone

How did you hear about us?

Medical Information

Are you taking any medications?

Yes No

if yes, please list name and use:

Are you currently pregnent?

Yes No

If yes, how far along?

Any high risk factors?

Do you suffer from chronic pain?

Yes No

If yes, please explain

What makes it better?

What makes it worse?

Have you had any orthopaedic injuries?

Yes No

If yes, please list

Explain anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you:

Massage Information

Have you had a professional massage before?

Yes No

What pressure do you prefer?

Light Medium Hard

What type of massage are you seeking?

Relaxation Therapeutic/Deep Tissue Other

Do you have any allergies or sensitivities?

Yes No

If yes,Please Explain

Do you have any difficulty lying on your front, back, or side?

Yes No

Are you wearing

Contact Lenses Dentures a hearing aid

If yes,Please Explain

Are there any areas (feet, face, abdomen, etc.) you do not want massaged?

Yes No

If yes,Please Explain

What are your goal for this treatment session?

Please Select any are as of discomfort

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Client’s Signature

Date