Alpenglow Massage Intake
Massage intake form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Have you received professional massage before?
How often and last time?
The pressure I prefer is?
Please Select
Light
Medium
Ashiatsu
Deep pressure will require choosing Ashiatsu.
Any Allergies or sensitivity that may be affected by a massage?
If Yes, please explain.
Any Medications that may be affected by massage?
If yes, what are they?
Do you suffer from chronic or acute pain at this time?
If yes, please explain cause, what makes it better or worse, are you under the care of a physician.
Elaborate if needed from medical question above
Please add anything I need to know
The following are contraindications for massage and you should not schedule with me without consent from your physician.
Cancer
Open cuts or wounds
Fever
Contagious disease
Kidney, heart or liver conditions
Blood clots
Pregnancy during the first trimester
Covid, Flu, cold, or other symptoms of illness
None of the Above
I agree I do not have any contraindications and can receive a massage without any health issues
I agree
I agree that if I am feeling discomfort, dizziness, or have any concerns, I will address them with my therapist during the service.
I agree
I acknowledge this is a professional massage meant for relaxation, improved circulation, lowered anxiety, help with pain management. No other service is implied or expected.
I agree and understand
Name
First Name
Last Name
Submit
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