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Home
Our Services
TMJ Myfocial Release Massage
Custom Integrative Massage
Certified Manual Lymph Drainage
Customized Facial
About
Testimonials
Gift Cards
Blog
New Clients
Contact
Home
Our Services
TMJ Myofacial Release Massage
Custom Integrative Massage
Manual Lymph Drainage
Customized Facial
About
New Client Forms
Gift Cards
Testimonials
Our Blog
Contact
Follow us on Instagram!
Home
Our Services
TMJ Myofacial Release Massage
Custom Integrative Massage
Manual Lymph Drainage
Customized Facial
About
New Client Forms
Gift Cards
Testimonials
Our Blog
Contact
Follow us on Instagram!
Book Now
intake form for massage therapy
Personal Information
First and Last Name
Date of Birth
Email Address
Phone Number
Your Address
Emergency Contact Name and Number
Health Information
Are you taking any medications?
No
Yes
If yes, please provide name and use.
Do you currently have or have had in the past the following conditions in any form, please check the appropriate box, please explain below.
Stress
Back Pain
Sensitivity or allergy to heat
Epilepsy or seizures
Diabetes
Open wounds, lesions, rashes, or infections
Headaches/migraines
Skin Problems/irritations
Currently pregnant or lactating
Broken bones in the past 2 years
Arthritis
Have you recently had surgery
High blood pressure
Varicose veins
Allergies
Cancer
Tension/soreness in a specific area. If so, where?
Numbness or stabbing pains anywhere. I so, where?
Any additional information that I should be aware of?
Is this your first massage experience?
Choose an option
No
Yes
If this is not your first, when was your last massage?
Please take a moment to read the following information:
I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this and future sessions, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and have answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
I also understand that if I cancel or do not show to any massage appointment without at least 24 hours notice, I am responsible for payment in full. I will be charged the cost of one-hour session and it will be due in full within three (3) days of missed appointment. (Our current pricing is listed on our booking page: https://jennawilkins.glossgenius.com/services)
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