Zobeautiful BEAUTY Massage Consultation Form

Massage Consultation Form

Confidential & Secure
Name*

First NameLast Name
Daytime Phone Number*
Please enter a valid phone number.Format: 00000000000.
Evening Phone Number*
Please enter a valid phone number.Format: 00000000000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Employer
Primary Physician*
Emergency Contact
Relationship*
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about us?
Medical Information
YesNo
Please list Medications and their use*
YesNo
If yes how far along?*
Any high risk factors?*
YesNo
If yes please explain*
What makes it better?*
What makes it worse?*
YesNo
If yes, please list:*
CancerHeadaches/MigrainesArthiritisDiabetesJoint Replacement(s)High/Low Blood PressureNeuropathyFybromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or StrainsVaricose VeinsUndiagnosed Lumps/BumpsOther
Please explain any conditions you have marked above:*
Massage Information
YesNo
RelaxationTherapeutic/Deep TissueOther
If Other please provide more information:*
LightMediumDeep
YesNo
Please provide details regarding any allergies/Sensitivities you may have:*
YesNo
Please explain:*
What are your goals for this treatment session?*
Please mark any areas of discomfort - Draw on Image Right, Front, Back, Left
By signing below, you agree to the following.

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Date*

DayMonthYear
Date
Client Signature*

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Therapist Signature*

Clear
Should be Empty:

Massage Consultation Form

Medical Information

Massage Information