Schedule an Appointment | Alex Ayal, Massage and Bodywork Therapist

Client Intake Form

Thank you for your interest in my practice! Please fill out the following paperwork, and I will then reach out to you to schedule an appointment. All information is held confident. At no given point is information disclosed or shared without client’s written consent.
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
E-mail*
example@example.com
Address (please enter if you are seeking a traveling service)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Information
Describe your treatment goals*
Is there anything I should know about your medical history? Please be as comprehensive as possible.*
Do you have any requests with regards to aromatherapy, massage oil, music, temperature, etc?
Please note that I have a cat named Beans. He will not be in the massage room with us (unless you'd like him to be - he loves to rest on your lap and purr), but if you have severe cat allergies, please let me know and I can put him in a room so he won't be around you at all.
How did you hear about my practice?
If you were referred to me by one of my previous clients, enter their name here and you will both receive $10 discounts for your next massage 😊 (redeemable once per new client)
Type of Appointment*
Traveling Service - $85/hr (I come to you), Home Studio Visit - $75/hr (you come to me)
How long a massage would you like?*

60 minutes / 1 hour90 minutes / 1.5 hours120 minutes / 2 hours
Please check the box to confirm that you have read the terms:*

Terms: Client information is confidential and written authorization is required to release any information. We do not double book appointments. Please reschedule session if more than 15 minutes late. 24 hour cancellation notice is required. You will be draped and at no time be exposed. You my end the session at any time for any reason. Inappropriate behavior will result in our session ending immediately.
Please check the box to confirm that you have read the client agreement:*

Client Agreement: I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction.I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.
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Client Intake Form

Health Information