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In Take Form
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Name (First, Last)
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First
Last
Birth Date
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Phone Number
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Occupation
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Address
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Email - reminders, survey, very occassional promo email, etc
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Emergency Contact
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Check all that apply
If you answer “Yes” to any of the following questions, please explain in the comments section below.
Do you have tension or soreness in a specific area?
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Yes
No
Have you ever had a professional massage?
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Yes
No
Do you have cardiac or circulatory problems?
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Yes
No
Are you pregnant?
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Yes
No
Do you suffer from back pain?
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Yes
No
Do you experience frequent headaches?
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Yes
No
Are you diabetic?
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Yes
No
Are you sensitive to touch / pressure in any area?
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Yes
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Do you bruise easily?
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Yes
No
Do you suffer from seizure disorders?
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No
Do you have phlebitis of varicose veins?
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No
Do you have any other conditions we should be aware of?
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Comments
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From a scale from
1
to
10
How do you like your pressure:
10
being very deep?
Swedish
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1
2
3
4
5
Deep Tissue, NMT
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6
7
8
9
10
How do you want to feel at the end of your visit?
*
Additional Comments
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Informed consent: Please take a moment to carefully read the following.
The above information is accurate to the best of my knowledge and I freely give my permission to be massaged. Since massage is contraindicated for some serious medical conditions, it may be necessary to obtain a doctor’s release or prescription before beginning therapy. I agree to inform the therapist of any experience of pain during the session. I understand that massage therapy should not be construed as a substitute for medical examination, diagnosis, and treatment, and that I should see a medical or chiropractic physician or other healthcare specialist. I agree to update the massage therapist in regard to changes in my health and understand that there shall be no liability on the therapist’s part should I forget to do so.
Cancellation Policy
If for any reason you have to cancel please give us a 24 hour notice. A cancellation less than 24 hours of your appointment or a no show will result in a $25 charge per person to your Credit Card or your Gift Certificate. Rescheduling with the 24 hours is also considered as a cancellation
By submitting below I agree to the above terms and consent.
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