Preferred Gender Pronoun
Cell Phone # (required)
Home Phone #
Work Phone #
Emergency Contact #
Permission to contact Physician
Referred by (required)
Do you have any past injuries or surgeries that you are still affected by?
Are you seeking medical treatment or under a doctor’s care for a chronic condition such as high blood pressure or arthritis?
If applicable, are you pregnant?
How many months?
Do you have any allergies? (i.e. allergies toward oil, lotions, and nuts)
Please let us know a little about your lifestyle. (i.e. hobbies, exercise, habits, etc.)
What is your primary reason for seeking massage services?
Stress ReductionPain ManagementInjury PreventionMuscular TensionImprove CirculationAnxietyOther
How often would you like to come for massage services?
Once every 3 monthsOnce a monthTwice per monthWeeklyAs neededSpecial Occasions
Pick your favorite appointment time:
Monday between 3pm and 6pmMonday between 6:30pm and 9pmTuesday between 3pm and 6pmTuesday between 6:30pm and 9pmThursday morningThursday afternoonFriday morningFriday afternoonSaturday morningSaturday afternoonSunday afternoonSunday evening
Please list any areas you DO NOT want worked on by the therapist? (Examples: buttocks, face, feet, ect.)
What kind of pressure would you prefer?
Soft/ Light touchMed / Firm touchHard / Deep touch
Look at the diagram below and please list areas of tension, stress or pain you are experiencing. Is the area of concern bilateral or on the right or left side?
The information I have provided is accurate and true. I have stated all my known medical conditions and I will take it upon myself to keep the massage practitioner updated on my physical health. I understand that this work does not constitute medical treatment. I also understand that this is a professional non-sexual massage service and the therapist or client reserves the right to stop the massage if boundaries are not respected.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present and future relating to massage therapy and bodywork.
Enter full name to sign (required)