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In Take Form
*
Indicates required field
Name (First, Last)
*
First
Last
Birth Date
*
Phone Number
*
Occupation
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email - reminders, survey, very occassional promo email, etc
*
Emergency Contact
Name
*
Phone Number
*
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?
*
Yes
No
Have you ever had a professional massage?
*
Yes
No
Do you have cardiac or circulatory problems?
*
Yes
No
Are you pregnant?
*
Yes
No
Do you suffer from back pain?
*
Yes
No
Do you experience frequent headaches?
*
Yes
No
Are you diabetic?
*
Yes
No
Are you sensitive to touch / pressure in any area?
*
Yes
No
Do you bruise easily?
*
Yes
No
Do you suffer from seizure disorders?
*
Yes
No
Do you have phlebitis of varicose veins?
*
Yes
No
Do you have any other conditions we should be aware of?
*
Yes
No
Comments
*
From a scale from
1
to
10
How do you like your pressure:
10
being very deep?
( Swedish 1-5 - Deep 6 -10 )
Swedish
*
1
2
3
4
5
Deep Tissue
*
6
7
8
9
10
How do you want to feel at the end of your visit?
*
Additional Comments
*
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.
Submit
Welcome
About Us
Services
Services
Packages
Massage Information
Gift Certificates
Learning Center
Learning Center
Our Team
Photo Gallery
Videos
Reviews
Policies
Forms
Intake Form
Request an Appointment
Private Event Form
Corporate Events Form
Health Fair Form
Donation Form
Join Our Team
Contact Us
Contact Us
Map
