Massage And Bodywork Intake Form: Use ONLY For Relaxation And Body Scrubs

Wellness & Treatment Intake Form

SOMATIC MASSAGE THERAPY & SPA
New Client Information
Full Name*

First NameLast Name
Phone Number*
Email Address*
Gender*

MaleFemaleOther
Birthday*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Information

NameRelationship
Phone Number
Please tell us how you heard about us:
Are you using a Gift Card / Gift Certificate?

YesNo
How would you like to provide your gift card details?

Enter card numberUpload a photo
Please enter the Gift Card / Gift Certificate Number and Value (if known)
Please upload a photo of your gift card or certificate

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MASSAGE INFORMATION

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Please indicate the service(s) you are receiving today:*

Body ScrubFacialMassageMassage & Body ScrubMassage & Facial
Have you had a professional massage before?

YesNo
Do you have any difficulty lying on your front, back, or side?

YesNo
Do you have any allergies to oils, lotions, or ointments?

YesNo
Do you have sensitive skin?

YesNo
If yes, please specify any allergies or sensitivities:
Including latex, fragrance, AHAs, penicillin, pollen, etc.
Do you have any chronic, ongoing pain that you deal with on a regular basis?

YesNo
Any recent surgeries or injuries?

YesNo
If yes, where?
Are you currently pregnant?

NoYes, First TrimesterYes, Second TrimesterYes, Third Trimester
What pressure do you prefer?

Light PressureMedium Pressure (Standard Swedish)Deep / Therapeutic: Requires a $45 upgrade
Are there any areas you would like your therapist to avoid?
Are there any areas you would like your therapist to focus on?
What do you hope to accomplish from today's massage?
Which scent will you choose for your glow?

Coffee: energizing, exfoliating, rich in antioxidants.Mango: nourishing, hydrating, and revitalizing.Peppermint: cooling, invigorating, and anti-inflammatory.Pumpkin: calming and skin-soothing.Unscented: gentle, non-irritating, and for sensitive skin.
What is your stress level today?

1

2

3

4

5

1 is Low Stress, 5 is High Stress
What is your pain level today?

1

2

3

4

5

1 is Low Pain, 5 is High Pain
Show us your pain and discomfort areas:
Treat yourself to the ultimate upgrade! Would you like to elevate your spa experience and leave feeling even more refreshed and radiant with one of our specialized add-on services?
Spa Add-Ons And Enhancements
Categories:All

All

Enhancements

Targeted Relief

Luxury & Spa Treatments

Specialty Treatments

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Enhancements

Aroma TherapyInvigorate your senses. Choose from our curated essential oils to relax, restore, and rejuvenate your mind and body.
$20.00 Quantity
Item subtotal:$0.00



Basalt Hot StonesRelaxing heat melts away tension. Add hot stones to your massage for deeper muscle relief and ultimate relaxation.
$35.00 Quantity
Item subtotal:$0.00



Pure CBD Infused Oil "May Contain THC"Soothe and restore with our CBD-infused oil. Enhance your massage for deep relaxation and ultimate tranquility.
$45.00 Quantity
Item subtotal:$0.00



Deep PressureRelieve chronic pain and muscle tension. Our deep tissue massage focuses on releasing knots and restoring mobility for lasting relief.
$45.00 Quantity
Item subtotal:$0.00



Targeted Relief

20 Min | Pain Relief Red Light TherapyRapid, targeted pain relief in 20 minutes. Soothe muscles, reduce inflammation, and heal faster with red light therapy.
$45.00 Quantity
Item subtotal:$0.00



30 Min | Medi-Cupping TherapyEnhance your massage with Cupping Therapy! Reduce pain and inflammation, improve circulation, release muscle tension, relax deeply, boost immunity, and melt away stress for a revitalized, balanced body and mind.
$20.00 Quantity
Item subtotal:$0.00



Theragun Muscle MassagerMaximize recovery and performance. Our targeted attachments offer deep tissue relief, soothing heat, and refreshing cold therapy for faster, more effective results.
$45.00 Quantity



30 Min | Ultrasound Therapy For PainUncover the source of your pain. Ultrasound for precise diagnosis, personalized care, and faster relief.
$45.00 Quantity
Item subtotal:$0.00



20 Min | Foot MassageElevate your massage. Add a soothing foot massage to melt away tension and leave you feeling completely renewed.
$35.00 Quantity
Item subtotal:$0.00



30 Min | Foot ReflexologyAdd on 30 minutes of foot reflexology to your service for a deep state of relaxation and well-being.
$35.00 Quantity
Item subtotal:$0.00



Luxury & Spa Treatments

Lavender Hand Paraffin TreatmentAdd on a lavender paraffin treatment for baby-soft hands, deep relaxation, and an extra touch of luxury.
$20.00 Quantity
Item subtotal:$0.00



Moisturizing Mask For Hands or FeetRevitalize hands with rose and strawberry extracts! Our hydrating, anti-aging treatment leaves skin soft, supple, and youthful. It's a hand spa in a mask!
$20.00 Quantity
Item subtotal:$0.00



Exfoliating Sugar Foot ScrubIndulge your feet! This **sugar scrub** exfoliates, softens, and revitalizes tired feet, leaving them smooth and refreshed. A perfect treat.
$20.00 Quantity
Item subtotal:$0.00



Exfoliating Sugar Back ScrubTreat your back! This sugar scrub exfoliates, nourishes, and renews skin, leaving it irresistibly smooth and glowing.
$40.00 Quantity
Item subtotal:$0.00



Specialty Treatments

30 Min | Thermal Infrared Sauna BlanketElevate your session! Detoxify, burn calories, and soothe muscles with our Infrared Sauna Blanket add-on for a deep, therapeutic cleanse.
$45.00 Quantity
Item subtotal:$0.00



40 Min | Table Steam SaunaElevate your spa experience with our 40-min Herbal Steam Canopy! Detox, boost immunity, and inhale the invigorating blend of ginger, rosemary, eucalyptus & clove. Emerge refreshed, energized, stress-free, and glowing—your ultimate wellness treat awaits!
$65.00 Quantity
Item subtotal:$0.00



Total

$0.00
Facial/Skincare Information
Have you had a facial treatment before?

YesNo
If Yes, when?
Do you have any chronic skin problems or concerns?

YesNo
If yes, please specify:
If you shaver your face, what is your current shaving system?

Wet ShaveElectric ShaveOther
If you shave your face do you experience irritation from shaving?

YesNo
Have you ever had a chemical peels, laser, or microdermabrasion?

YesNo
Do you use Retin-A, Renova, Adapalene, Hydroxyl Acid, or Retinol/Vitamin A derivative

YesNo
Have you recently used any self-tanning lotions, Creams, or treatments?

YesNo
If yes, please specify:
Do you use SPF on your face?

YesNoSometimes
How often do you use SPF?
Have you experienced Botox, Restylane, or collagen injections?

YesNo
Have you used any acne medication?

YesNo
Are you undergoing any hormone replacement therapy?

YesNo
Are you taking any oral contraceptives?

YesNo
If yes, please specify and list any medications you take that may affect your skin:
What would you like to achieve from your facial treatment?
"Optional" Take A Facial Photo
SCOPE OF PRACTICE

Massage therapy is a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies, to positively affect the health and well-being of the client. Massage Therapists do not diagnose or prescribe for medical conditions nor are they allowed to provide treatment for a specific condition without a doctor's supervision. The massage therapist is required to refer you for diagnosis and to follow the recommendations of your physician. The massage therapist is happy to adjust pressure, and table temperature, work longer on an area, or move on if you request it.

MEDICAL CONDITIONS
It is the client's responsibility to keep the massage therapist informed of any medical treatment currently being taken, and to provide written permission from the physician, physical therapist, etc., that the massage may be continued. The client must also inform the massage therapist of any changes in health conditions.

CANCELLATION POLICY
Our goal is to provide quality care in a timely manner. In order to do so, we have had to implement an appointment/cancellation policy. Appointments are in high demand, and your early cancellation will give another person the opportunity to have access to timely care. This policy enables us to better utilize available appointments for our clients.

If you need to cancel or reschedule your appointment you must call at least 24 hours prior to your appointment, providing less than 24 hours' notice will require you to pay the full-service price as a fee. If you arrive more than 15 minutes late for your appointment without notice it is considered a no-show and you will be charged the full-service price to your card on file.
My signature acknowledges that I have read and agree to receive the massage therapy and that I will adhere to all of the aforementioned statements that I have checked off. I agree to waive all liability toward my technician and the spa for any injury or damages incurred due to any misrepresentation of my health. I have read and fully understand the above Appointment Cancellation Policy and agree to be bound by it's terms. I agree to pay the cancellation fee in the event of a missed appointment. I understand that this consent agreement is legal and binding.*

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Wellness & Treatment Intake Form

New Client Information

MASSAGE INFORMATION

Facial/Skincare Information