Massage Intake
Please only fill out the spots below that correspond to your massage service
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 Add-on / Uplifting Face Massage
Please only fill out if you are receiving this service
Have you had any botox/fillers or chemicals peels in the last two weeks? If yes, please list the date below.
Do you get your face waxed? If so, please list the date of last wax:
Do you experience headaches often?
Do you have jaw pain or have you been diagnosed with TMJ issues?
Barefoot Massage
Please only fill this out if you are receiving this service
Barefoot Massage: Have you had barefoot/Ashiatsu massage before?
Please Select
Yes
No
Barefoot Massage: What type of pressure do you prefer?
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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