Hot Stone Massage consultation

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Where do you feel tension/tightness in your body?

How is your energy level today?

In general, how is the stress in your life?

How do you experience stress?

List an additional areas of discomfort

Describe onset of discomfort/ pain

Any areas you would like avoided (I.e legs, back, shoulders etc.)

Are you okay with pressure?

Preferred Aroma

Are you pregnant or nursing?

Any known allergies (nuts, latex, certain foods, etc.

I consent to video for the purpose of documentation, potential advertising and promotional purposes.

Client services and chart information are confidential. Written authorization is required from you to release any information.

•Please turn off your cell phone for optimal relaxation. Your scheduled session is set aside for you. We do not double book appointments

•Please reschedule your session if you are more than 10 minutes late. After 10 minutes, I do reserve the right to cancel and charge the cancellation fee as agreed upon.

•24 hour cancellation notice is required to avoid being charged for your session.

•You will be draped and at no time will genitalia or breast tissue be exposed. If at any point in time the esthetician feels you are being inappropriate, I do reserve the right to IMMEDIATELY stop service. Full amount will be charged and you will be banned from future bookings.

•You will have a consultation with your esthetician to discuss your session. Should the session require, after your therapist has left the room, you may disrobe to your comfort level. Please keep underwear/shorts ON

Signature

Date