Massage Intake
Please fill this form out before your appointment (if you are having a barefoot or face massage, please fill those areas out as well)
Name
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First Name
Last Name
Is this your first time getting a massage?
Please Select
Yes
No
Are there any areas of the body you would like to avoid being massaged?
Head, feet, area that is too sensitive, etc...
Face Massage / Uplifting Face Massage: Have you had any botox/fillers or chemicals peels in the last two weeks? If yes, please list the date below.
Face Massage / Uplifting Face Massage: Do you get your face waxed? If so, please list the date of last wax:
Face Massage / Uplifting Face Massage: Do you experience headaches often?
Face Massage / Uplifting Face Massage: Do you have jaw pain or have you been diagnosed with TMJ issues?
Barefoot Massage: Have you had barefoot/Ashiatsu massage before?
Please Select
Barefoot Massage: What type of pressure do you prefer?
Is there anything else I should know before your massage?
Questions/concerns
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law.
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Today's Date
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Month
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Day
Year
Date
Submit
Should be Empty: