Massage Consultation Form
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Postal / Zip Code
Phone Number
*
Format: 000 00000000.
Email
*
example@example.com
Please list allergies or sensitivities:
*
Please list Injuries or surgeries:
*
Preferred Massage Pressure?
What is your stress level right now?
Low
Average
Somewhat Stressed
Very Stressed
Please check all that apply.
*
Pregnant
Postpartum
Neck Pain
Back Pain
Headaches
High Blood Pressure
Bruise Easily
Diabetes
Seizures
Knee/Leg Pain
Jaw Pain / Clenching/ Grinding
Metal Implants
Fibromyalgia
Used Retin -A within the past 10 days?
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: