CLIENT INFO:

Full Name *

Email *

Phone *

Date Of Birth *

Address *

Massage modalities *

Massage modalities

Swedish Massage
Deep Tissue Massage
Sports Massage
Assisted Stretching
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Preferred Date for Massage

Are there any areas you prefer not to have massaged? *

Any Specific Concerns or Goals for the Massage? *

MEDICAL HISTORY:

Any Known Medical Conditions *

Current Medications *

Any Allergies? *

Any chronic conditions, such as high blood pressure, diabetes or arthritis?

ADDITIONAL INFO:

Any Additional Comments, Questions Or Special Requests?

Consent and Agreement. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. As such, the therapist does not prescribe medical treatment or pharmaceuticals. I acknowledge that massage is not a substitute for medical examination or diagnosis, and it is recommended that I see a physician for any physical ailment that I might have.