Street. Add. ________________________________________
City ________________________ ST _____ Zip ___________
Occupation ___________________Marital Status? ________
Birth Date _______________________
Telephone # _____________________
Business # ______________________
Have you received Therapeutic Massage? Yes ___ No ____ If so, how often? ____________
What is the reason for your visit today? __________________________________________________
Are there any areas you want me to concentrate on?______________________________________
Do you prefer a deep or light massage?_______________ Do you like stretches?_____________
Are there any areas you wish not to treat?_______________________________________
Are you under the care of a physician or other health care practitioner?_________
If yes, for what?__________________________________________________________________
Are you pregnant? __________ If yes, what trimester?________
Are you having any problems that I should know about? _________________________________________________
If so, do you have a doctor’s consent?___________________________________________________
Do you want your abdomen massaged? _____________ Around Breast?_______________________
List any medications you are now taking and what they are used for: _________________________
Please check off any of the following conditions or symptoms which apply to you now or in the past:
____high blood pressure
____low blood pressure
____use of tobacco
____allergy to perfumes or oils
This massage is for therapeutic purposes only and completely NON-SEXUAL. Your cooperation is expected.
I understand the massage services are designed to be a health aid and are in no way to take the place of a doctor’s care when it is indicated. Information exchanged during any massage session is educational in nature and is intended to help you become more familiar and conscious of your own health status and is to be used at your own discretion.
CANCELLATION POLICY: A 24 hour cancellation notice is required. If I do not receive 24 hour notice you will be sent a bill for the missed appointment, and in the future you will be required to give a credit card when booking your appointment.
Your appointment time has been set aside especially for you. If you are unable to keep the appointment, then there must be enough notice given so others who are waiting have the opportunity to reserve that time.
Name (signature) _________________________________________ Date _____________________
If you would like to receive notification of specials please give me your email address: __________________________________________