Honeywell Massage Intake Form

Your Privacy is a Priority "At Honeywell Massage, your health and personal information are handled with the highest level of confidentiality and security. This intake form is encrypted and used solely by your therapist to design a safe, effective treatment plan tailored to your needs. We strictly adhere to professional privacy standards to ensure your data remains protected."

Location: 16614 N Dale Mabry Hwy, Tampa, FL 33618

Phone: 813-445-1367

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date Of Birth:

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Occupation (Helps To Identify Repetitive Stress)

Does your day involve long periods of sitting, standing, or repetitive movement (e.g., 'Tech Neck' or 'Driving')?

Emergency Contact:

Relationship

Emergency Contact Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Are you just updating your medical history today?

Protocol Notice: Clinical Separation

To ensure the safety and efficacy of your treatment, Lypossage, MLD, and Wood Therapy are performed as dedicated clinical protocols. These services cannot be combined with other rituals (like Body Scrubs or Bespoke Massages) on the same day to avoid overtaxing your lymphatic system.

Next Steps:

Please select only your clinical service today.
You may book a complementary ritual for a separate date (at least 24 hours apart).
We recommend preparing for your clinical session by hydrating with water to support the metabolic flush.

Which service are you booking today? Select all that apply

Where will we be meeting today?

Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Total Booking Time

Appointment 20 minute

Appointment 30 minute

Appointment 40 minute

Appointment 60 minute

Appointment 90 minute

Appointment 120 minute

Appointment 210 minute

Medical History:

Please check if any of these pertain to you. Your answers help us tailor a safe session for you.

MUSCULOSKELETAL

CIRCULATORY / HEART

NEUROLOGICAL / SENSORY

GENERAL HEALTH

Other conditions we should know about:

Have you had a massage before? If so, when was your last massage?

What is your primary goal for today? (e.g., Deep sleep, body contouring, mobility, pain relief, or mental clarity)

What kind of pressure would you like? (Light, medium, deep)

What is your primary goal for the Couples Class? (e.g., Learning to help with partner's chronic back pain, a fun date night activity, learning relaxation techniques)

If this does not apply to you, write N/A.

Do either of you have previous experience or training in massage or bodywork?

On a scale of 1–5, how comfortable are you giving and receiving feedback during the practice portion of the session?

Do you have any open wounds, active skin infections, or open wounds?

Does either partner have any joint issues, recent surgeries, or chronic pain points that the instructor should be aware of before demonstrating techniques?

Are there any physical limitations that would make standing or leaning over a table/bed for 15–20 minutes difficult for either partner?

Will we be practicing on a professional massage table, a floor mat, or a standard bed? (This helps the instructor prepare the correct ergonomics to teach you)

Is there a quiet space with enough room for the instructor to move around the 'practice area' to demonstrate techniques?

Would you like to learn how to incorporate essential oils? If so, what scents would you like? i.e. Calming Lavender, Uplifting Citrus, or Grounding Eucalyptus

You can choose a scent not listed and I will provide it for your session, if it is available.

Would you prefer our signature 693 Hz Solfeggio frequency music or a different ambient style during your instruction?

Who do you like to listen to? And What genre of music do you like?

My Products

Bespoke Massage

Experience a fully customizable clinical massage tailored to your body's specific needs. Your session is uniquely crafted using a blend of techniques including Swedish Relaxation, Deep Tissue, Thai Stretching, Reflexology, Prenatal, or Geriatric massage. You choose your preferred pressure—Light, Medium, or Deep—and can further enhance your recovery with integrated Red Light Therapy. Whether you need intensive therapeutic work or pure relaxation, this session is designed exclusively for you. Specialized enhancements (Cupping, Aromatherapy, or Hot Stone) are available for an additional $20.

$170.00

Duration & Location	Quantity	Price
60 Min - In-Studio		$170.00
60 Min - Mobile Concierge		$200.00
90 Min - In-Studio		$255.00
90 Min - Mobile Concierge		$300.00
120 Min - In-Studio		$340.00
120 Min - Mobile Concierge		$400.00

Session Enhancements

Enhancement: Cupping Therapy

Our signature recovery enhancement. This duo pairs the deep myofascial release of clinical cupping with a complimentary application of high-grade Magnesium to your primary area of tension. This combination is specifically designed to lift restricted tissue and improve circulation while the magnesium works to soothe the nervous system and prevent muscle cramping. The ultimate choice for deep tissue recovery and chronic tension relief.

$30.00

Enhancement: Luxurious Hot Stone

Smooth, heated basalt stones are integrated into your session to provide deep, penetrating warmth that softens muscle tissue and promotes profound relaxation. Bespoke Benefit: If desired, this enhancement can be paired with our clinical aromatherapy at no additional cost. Please let your therapist know your preference.

$30.00

Enhancement: Bespoke Aromatherapy

Elevate your clinical session with a customized blend of therapeutic-grade essential oils tailored to your wellness goals. Designed to enhance your sensory experience and support muscle recovery. Bespoke Benefit: If desired, this enhancement can be paired with our luxurious hot stone therapy at no additional cost. Please let your therapist know your preference.

$30.00

Single Specialty Sessions

Wood Therapy

A vigorous clinical massage technique using sculpted wooden tools to break up localized fat, diminish cellulite, and contour the body.

$115.00

Select Duration & Areas	Quantity	Price
30 Min (One Area) - In-Studio		$115.00
60 Min (Two Areas) - In-Studio		$195.00

Gua Sha Ritual

A therapeutic treatment using specialized tools to improve circulation, reduce inflammation, and release deep myofascial tension.

$195.00

Duration & Location	Quantity	Price
60 Min - In-Studio		$195.00
60 Min - Mobile Concierge		$225.00
90 Min - In-Studio		$290.00
90 Min - Mobile Concierge		$335.00

Manual Lymphatic Drainage (MLD)

A gentle, clinical technique designed to stimulate the flow of lymph, reduce swelling, and support the body's natural detoxification.

$170.00

Select Duration & Areas	Quantity	Price
30 Min - In-Studio (One Area)		$170.00
30 Min - Mobile Concierge (One Area)		$200.00
60 Min - In-Studio (Two Areas)		$255.00
60 Min - Mobile Concierge (Two Areas)		$300.00

Results-Based Series (Save with Packages)

Lypossage® Clinical Transformation Series (20 Sessions)

Zone 1: Stomach, Glutes, and Thighs. Zone 2: Arms, Back, and Bust. Zone 3: Face and Neck. Note: Lypossage® is an In-Studio Only service to ensure we have the professional equipment and measurement tools on hand to track your transformation accurately.

$3,060.00

Select Your Treatment Area(s)	Quantity	Price
Single Zone (Choice of Zone 1, 2, or 3)		$3,060.00
Dual Zone (Any 2 Zones combined)		$5,760.00
Full Body (All 3 Zones combined)		$8,010.00

Wood Therapy Results-Based Series

Commit to your transformation with our discounted series packages. Ideal for consistent body contouring and lymphatic support.

$325.00

Select Your Package	Quantity	Price
3 Sessions - One Area		$325.00
5 Sessions - One Area		$545.00
3 Sessions - Two Areas		$565.00
5 Sessions - Two Areas		$945.00

Luxury Body Rituals (Shower Access Required)

The Signature Glow Ritual (Body Scrub)

A transformative skin-refining treatment using organic botanicals to polish away dullness and stimulate cellular turnover.

$345.00 Quantity

The Thermal Detox Ritual (Body Wrap)

An intensive metabolic reset using a heated cocoon to draw out impurities and soothe deep-seated inflammation.

$375.00 Quantity

The Ultimate Concierge Renewal (Combined)

Our most prestigious mobile offering, combining mechanical exfoliation with a nourishing body mask.

$485.00 Quantity

Private Wellness Instruction

The Art of Connection: Private Couples Workshop

Elevate your relationship with the gift of therapeutic touch. In this exclusive one-on-one session, I guide you and your partner through professional massage techniques tailored specifically for one another.

$475.00

Session Location	Quantity	Price
Studio Mastery Session (In-Studio)		$475.00
In-Home Boutique Workshop (Mobile)		$595.00

The Signature Glow & Connection: A Boutique Couples Workshop

Experience the Art of Connection & Ritual. Transform your home, office, or hotel into a sanctuary with this immersive 2-hour boutique experience. This signature workshop is designed for partners to bond through the creation of personalized wellness rituals and the mastery of therapeutic touch. The Experience Includes: Artisan Apothecary Session: Together, you will hand-blend a custom organic botanical body scrub using organic sugar, virgin coconut oil, and premium essential oils. Guided Glow Ritual: Learn the professional technique of applying a scrub to your partner’s skin—focusing on a "mini-massage" flow that exfoliates and relaxes without irritation. Instructional Mastery: A 90-minute guided massage workshop where I teach you how to soothe tension and connect through touch, tailored to your partner's specific needs. Important Requirements: Mobile Concierge Only: This service is performed exclusively in the comfort of your home, office, or hotel. Private Shower Access: A private shower is required for the client's post-treatment rinse.

$795.00

The Signature Glow & Connection: A Boutique Couples Workshop	Quantity	Price
Glow & Connect: A Boutique Couples Workshop		$795.00
Add 90-Minute Private Massage Instruction		$495.00

New Client Specials

The Signature Introduction Bundle

New to my practice? Experience the full range of my modalities with a 3-session "Discovery" package. Includes a personalized wellness plan and one complimentary Hot Stone upgrade.

$715.00

The Signature Introduction Bundle	Quantity	Price
3 In-Studio Sessions (90 min)		$715.00
3 Concierge Mobile Sessions (90 min)		$850.00

Monthly Wellness Memberships

Concierge Elite Membership (Monthly)

Includes one 60-min session/mo + 10% off additional sessions. By purchasing, you agree to monthly recurring billing.

$170.00

Concierge Elite Membership (Monthly)	Quantity	Price
The Studio Monthly		$170.00
The Concierge Monthly		$200.00

Commit to Calm Series

Commit to Calm: 10-Session Seriesm (In Studio)

Your 10th session is on us! Valid for 12 months.

$1,530.00 Quantity

Commit to Calm: 5-Session Series (In Studio)

Includes a $100 credit toward your 6th session! Valid for 12 months.

$850.00 Quantity

Signature Extension Rituals

The Apothecary Scalp & Crown Ritual (+30 min)

The ultimate antidote to mental fatigue and 'Tech Neck.' This ritual focuses on the upper gate of the body—the scalp, jaw, and neck. Using warmed, bespoke therapeutic oils selected for your current needs, we perform a rhythmic cranial release that melts away tension and quietens the mind. A luxurious extension that leaves you feeling deeply rested and mentally clear.

$55.00

The Botanical Earth & Sole Ritual (+30 min)

An invitation to ground and center. We begin with a hand-blended organic exfoliation using mineral-rich salts and seasonal botanicals to renew tired skin. This is followed by a focused 20-minute therapeutic reflexology-style massage using our signature magnesium-infused cream and warming towels. Perfect for those who spend their days on their feet and seek a deep, stabilizing sense of renewal.

$55.00

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Total

Payment Methods

Debit or Credit Card

ACH Bank Transfer

Klarna

Honeywell Massage: Membership & Package Terms

Monthly Memberships: By selecting a "Concierge Elite" membership, you authorize Honeywell Massage to initiate a recurring monthly charge via Stripe. Memberships include one (1) 60-minute session per month and a 10% discount on additional services.
Commit to Calm Series: Series of 5 or 10 sessions is valid for 12 months from the date of purchase. These sessions are non-transferable and non-refundable.
Cancellation Policy: We require a 24-hour notice for all cancellations. Late cancellations or "no-shows" will result in the forfeiture of that session from your series or membership.
Usage: These introductory offers and series credits are not applicable toward Lypossage® Clinical Transformation sessions.

Agreement & Authorization: I have read and agree to the Membership terms, the 24-hour cancellation policy, and authorize recurring billing for membership selections.

INFORMED CONSENT & LIABILITY WAIVER

1. Scope of Practice: I understand that the massage therapy provided by Honeywell Massage is for the specific purpose of relaxation and relief of muscular tension. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. The massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform spinal manipulations.

2. Medical Release: Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

3. Liability Release: I understand that massage therapy involves the use of touch and that physical injury can occur. I hereby release Honeywell Massage, its therapists, owners, and employees from any and all liability, past, present, and future, for any injury, illness, or damage that may result from my participation in this massage session. I specifically hold Honeywell Massage harmless for any exacerbation of pre-existing conditions that I failed to disclose.

4. Client Comfort & Safety: I understand that I have the right to stop the massage at any time for any reason. If I experience any pain or discomfort, I will immediately inform the therapist so the pressure or strokes may be adjusted.

5. Inappropriate Conduct: I understand that any illicit or sexually suggestive remarks or advances made by me will result in the immediate termination of the session, and I will be liable for the full payment of the scheduled appointment.

6. Cancellation Policy: Your appointment time is reserved specifically for you. If a cancellation notice is not received at least 24 hours in advance, you agree to pay for the full amount of the missed service.

By signing below, I acknowledge that I have read and understand the above policies and agree to be bound by them.

Client Signature

Date

(If client is under 18) Parent/Guardian Signature:

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