Massage Consultation Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have any allergies?
*
Yes
No
List allergies here
Are you currently taking any medications?
*
Yes
No
List any that may affect your service today:
Have you been recently hospitalized?
*
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
*
If yes, please specify on the field above.
Current Medical Conditions?
*
Asthma
Diabetes
Heart Problems
Kidney Problems
Epilepsy
Scoliosis
Communicable Disease
Other
None
If you selected 'Other,' please list here:
Do you have any current injuries?
*
Yes
No
Please list below:
Annotate Image
*
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
*
I agree
I understand that oils can damage my jewelry, clothes and/or accessories and I will dress accordingly for my appointment. I understand that the salon and the technician is not liable for any accidental damages.
*
I agree
I understand the risks associated with massage therapy include, but are not limited to: superficial bruising or redness, short-term muscle soreness, exacerbation of undiscovered injury. l release my massage therapist and salon of all liability concerning these injuries that may occur during the massage session.
*
I agree
I understand the importance of informing my massage therapist of all medical conditions and medications I am taking on this form, and to let them know about any changes to these and that there may be additional risks based on my physical condition.
*
I agree
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
*
I agree
I understand that if I cancel my appointment with less than 24 hours I will be charged 75% of the service fee. If I no show my appointment, I will be charged 100% of the service fee. Repeated late cancellations will result in a deposit being required to book for all future appointments.
*
I agree
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: