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*

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Phone Number*
Email Address*
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Birthday*

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Emergency Contact Information

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Please tell us how you heard about us:
Are you using a Gift Card / Gift 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, Kelp, Biofreeze, menthol, or similar products etc.
Do you have any of the following medical conditions? (Check all that apply)
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 session?
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
Based on your current stress level, we recommend our Tranquil Escape aromatherapy blend (lavender, bergamot, ylang ylang) to deepen relaxation. We also offer CBD Infused Oil for clients seeking deeper nervous system support and anxiety relief.

Please note: Our CBD Infused Oil contains trace amounts of THC. If you'd like to add either option to your massage, please notify your therapist or the front desk. (+$20 aromatherapy blend or +$45 CBD)
What is your pain level today?

1

2

3

4

5

1 is Low Pain, 5 is High Pain
Based on your current pain level, we recommend enhancing your massage with our Deep Relief CBD Infused Oil for targeted inflammation and muscle recovery. We also offer our Deep Relief aromatherapy blend (eucalyptus, peppermint, rosemary) if you prefer a sensory-focused approach.

Please note: Our CBD Infused Oil contains trace amounts of THC. If you'd like to add either option to your massage, please notify your therapist or the front desk. (+$45 CBD or +$20 aromatherapy blend)
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
prevnext( X )
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



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



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



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



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



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



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



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 | 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



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



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



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
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Wellness & Treatment Intake Form

New Client Information

MASSAGE INFORMATION

Facial/Skincare Information

TERMS & CONDITIONS - LEGALLY BINDING AGREEMENT

MANDATORY ACKNOWLEDGMENTS