Massage Form

Massage Form

New Client Intake Form
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
Date of Birth*

MonthDayYear
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Low Back PainSciatic PainNeck PainHip PainBloatedShoulder IssuesTension HeadachesOther
Stabbing PainElectrical Pain (Sharp Electric Shock)Burning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainSharp Pain, Localized, Small AreaNoneOther
Any Orthopedic SurgeryCarpal Tunnel SurgeryRotator Cuff SurgeryNeck / Back FusionKnee SurgeryHip ReplacementAnkle SurgeryGallbladder SurgeryHysterectomyBreast SurgeryLymph Node RemovalNoneOther
Cosmetic SurgeryCancerPregnancyOther

I AGREE THAT A 48 HOUR NOTIFICATION IS REQUIRED TO AVOID A $40 CANCELLATION FEE OR A $40 RESCHEDULING FEE. I UNDERSTAND THAT IF I AM 10 MINUTES LATE FOR MY APPOINTMENT IT WILL BE CONSIDERED A NO-SHOW AND THE CANCELLATION FEE WILL BE APPLIED. I AGREE TO THIS POLICY AND CONSENT THE SPA TO CHARGE MY CARD ON FILE THAT WAS PROVIDED WHEN BOOKING.
Informed Consent
Type Full Name:*

First NameLast Name
Signature*
Today's Date*

MonthDayYear
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