Massage Intake Form & Waiver

Massage Intake Form & Waiver
Please fill this form out the best you can. You will also have a brief personal consultation with Dominique prior to your treatment. You are not required to fill this out before each session.
Name*

First NameLast Name
Email*
example@example.com
Social media handle: (ex: @devotedhealing)
Phone Number*
Please enter a valid phone number.
How do you enjoy spending your time or what you do for work?
Do you have allergies?
Any injuries to know about?
Are you pregnant or nursing?
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
Is there anything that's important for Dominique to know about your session that will support your time together?
Terms and Agreements:

Please read through these and indicate your acceptance at the top box below.
Signature*

Clear
Should be Empty:

Terms and Agreements: