Massage Intake Form

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Full Name*

Cell Phone #*

Email Address*

Date of Birth*

Health History (Check any that apply)

High Blood Pressure

Diabetes

Pregnancy

Recent Surgery

Current Injury

Chronic Pain

Heart Condition

None

Is there anything important we should know before your session?*

Service Requesting (You can select more than one option)*

Relaxation Massage ($65.00 for 1 hour)

Swedish Massage (Price upon request)

Deep Tissue Massage (Price upon request)

Advanced Relaxation Therapy (Price upon request)

Reflexology Therapy ($45 for 40 minutes)

Facial Massage Therapy (Price upon request)

Hot Stone or thermal Elements ($15 add-on)

Aroma Therapy (Price upon request)

Body Exfoliation Treatment (Price upon request)

Massage Preference*

Light

Medium

Deep

Are there areas to avoid?*

Do you have any allergies (oils, lotions, aromas, etc.)

CONSENT: By putting my initials in the box below, I confirm that the information provided is accurate. I understand that massage therapy is not a substitute for medical treatment, and I consent to receive bodywork services.*Initials

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