Gust Check In Form

Please help us to serve you by completing the client information form.

Date

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Please enter a valid phone number.

Would like to receive special discounts and promotions via email ？

Yes No

Where did you hear about us? *

Have you received a professional massage in the past? *Sore or tight muscles is normal after a massage, especially if it has been a while since your last massage or you never had one before.

Yes No

How long ago was the approximate date of your last massage ?

Are you current pregnant (Female)?

Yes No

How far long and any high risk factors ?

Are you taking any medications?

Yes No

Please list current medications & the conditions they are treating below

Please indicate any of the following that apply to you

Have you recently had any orthopedic injuries or surgery？ *

Yes No

Please explain :

Are you allergic to organic coconut oil? *

Yes No

What service are you receiving ?

Full Body Massage Foot Massage Both

What pressure do you prefer for your massage?

Light Medium Deep

Client Agreement

I understand that massage therapy is provided for the basic purpose of relaxation and relief of muscle tension. Massage therapy is not a substitute for medical diagnosis and/or treatment. If I experience any pain or discomfort during the session, I will alert the practitioner so modifications can be made. Because massage therapy is contraindicated under certain medical conditions, I agree to fully disclose all of my known medical conditions and medications. I agree to keep my medical profile updated and understand that there shall be no liability on the practitioner’s part should I fail to do so. I agree to consult with my physician if I have any concerns with receiving massage therapy prior to attending a massage therapy appointment. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will still be responsible for full payment of the session.

Please Sign your name below *

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