Massage Intake Form

COVID-19 information: MASK NOT REQUIRED.. If you feel safer wearing a mask that is your choice and I will not tell you otherwise. I, however, will not be wearing one. I have natural immunity as I have had covid THRICE. I will not shun you about your decisions and you will give me the same courtesy.

Name*

First NameLast Name

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Preferred Contact Phone Number*

Area CodePhone Number

Is this a cell number?*

Date of Birth*

MonthDayYear

Location you scheduled*

How did you hear about me or who recommended you see me? Referred by: Google, Friend, Family

In case of emergency...

Emergency Contact:*

First NameLast Name

Relationship*

Contact Number*

Area CodePhone Number

Reason for Massage*

Have you ever experienced a professional massage? How recently?*

2 part question Yes/No and How recent

Do you frequently suffer from stress*

Do you have diabetes?*

YesNo

Do you suffer from Arthritis or Osteoporosis?*

YesNo

Are you pregnant?*

YesNo

Do you have high blood pressure?*

YesNo

Taking any medications, currently?*

YesNo

If yes to taking medications, please list here

Have you been in an accident or injured in the past two years?*

YesNo

If yes, please explain injuries.

Broke xyz, Surgery on xyz, Whiplash etc

Do you sit at a computer daily?*

YesNo

How many hours?

Do you bruise easily? Light pressure causes bruising. Not finding furniture in the dark with your body kind of bruising.*

YesNo

Are you Sensitive to touch or pressure in any area? If area touched you will literally levitate off the table while speaking in tongues.*

YesNoDepends on the day

If Sensitive to touch or Pressure, please list areas here.

Spot in middle of back, Legs, Feet, etc

Are there any areas you would rather not have worked?*

YesNo

If there are areas you don't want worked, please list it here

Glutes, Feet, Neck etc

Do you have tension or soreness in a specific area?*

Specify Area

Do you have numbness or stabbing pain in a specific area?*

Specify Area

Do you have any other medical conditions or other concerns you want me to know about or discuss?

Payment methods accepted at time of service or prepay:

Card, Cash, Venmo, Paypal, local checks...sometimes food but no animals large or small :)

Credit Card Form available for pre-pay services below.

Services Available ************************** DO NOT SELECT SERVICE OR ENTER CARD IF NOT PAYING WITH CREDIT/DEBIT CARD !!!! **************************

30m massage$40.00

Focused area massage: on the neck and back muscles or low back and legs or arms and hands or legs and feet. Great after a day of hiking and carrying a pack, yard work or dealing with everyday stress.

60m massage$70.00

Basic full body massage designed to sooth sore muscles, reduce tension, increase circulation and promote relaxation

90 min Massage $100.00

Full body massage designed to soothe muscles, provide relaxation and allows the therapist to focus on specific areas of concern or injury and apply a wider array of techniques.

45m Relaxing Feet$40.00

A great way to help those tootsies get ready for the next day of hiking, biking or climbing. Beginning with a warm foot soak, followed by an invigorating scrub and ending with a relaxing foot massage.

75m Hot Stone Massage$100.00

A hot stone massage is used to help you relax and ease tense muscles and damaged soft tissues throughout your body. During a hot stone massage, smooth, flat, heated stones are used on your body. The stones are made of basalt, a type of volcanic rock that retains heat. Hot massage stones are heated to between 120 and 140 degrees. Combined use of warm, smooth stones and massage strokes make this a uniquely relaxing, detoxifying and stress relieving massage.

60m Reiki$50.00

Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. It is administered by "laying on hands" light pressure that helps balance and restore the unseen "life force energy" (Meridians/Chakras/Energy Pathways). If one's "life force energy" is low, then we are more likely to get sick or feel stress, and if it is high, we are more capable of being happy and healthy. This also helps with emotional issues.

60m Cranial Sacral$50.00

CranioSacral Therapy (CST) is a gentle, hands-on approach that releases tensions deep in the body to relieve pain and dysfunction and improve whole-body health and performance. Using a soft touch which is generally no greater than the weight of a nickel practitioners release restrictions in the soft tissues that surround the central nervous system. CST is increasingly used as a preventive health measure.

60m Lymphatic Drainage Massage$70.00

Lymphatic drainage massage is a form of gentle, rhythmic movement that encourages the movement of lymph fluids around the body. The lymph is just under the skin. The fluid in the lymphatic system helps remove waste and toxins from the bodily tissues. Lymphatic drainage massage can benefit people who are experiencing the following: lymphedema, fibromyalgia, swelling or edema, non-infectious skin disorders, fatigue, insomnia, stress, digestive problems, arthritis, migraine episodes, post surgical edema.

Gratuity$20.00

If you would like to add gratuity select option below. Thank You

Total $0.00

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Emalene Lake Licensed Massage Therapist

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