Massage/Reiki Intake Form

Massage/Reiki Intake Form

In-House Application
Full Name

First NameLast Name
What is your age?
What is your gender?
Contact Number
Email Address
example@example.com
Address (where you'd like your massage session to take place)

Street Address

Street Address Line 2

*City*State / Province

*Postal / Zip Code
Check the conditions that apply to you or any member of your immediate relatives:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Check the symptoms that you' re currently experiencing:

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther
Are you currently taking any medication?

YesNo
Please list them.
Do you have any allergies?

YesNoNot Sure
Please list them.
Do you use any kind of tobacco?
Do you currently use any kind of illegal drugs?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
For the safety of everyone involved, for all in-house massages we require a picture of your Photo ID before your appointment is approved. Please upload your ID below.
File Upload

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IMPORTANT: Once approved, you will receive an approval email with appointment days and times for you choose from, as well as a request for a deposit to secure your appointment. The deposit will be 25% of your total massage price. Your remaining balance will be due at the time of the appointment via cash, venmo, zelle or paypal.

Our cancellation policy reqiures you to cancel within 24 hours or more for a full refund of the deposit. If cancellation within less than 24 hours of your appoinment time or a no-show occurs, deposit is non-refundable.

By signing below, you approve that all questions have been answered sincerely and consent to all statements and policies above.

Sincerely,

Maily Milo, LMT

LN: MA88243
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