We want to make your massage as beneficial as it will enjoyable.
Take a moment to provide us this information.



Types of massage recieved before


Exercise

frequency:

/week

Duration of workout

Medications


Do you have any issues such as these?

accident or injury
surgery
headaches
joint issues
disk problems
neck pain
back pain
decreased range of motion

broken bones
carpal tunnel syndrome
sciatica
nerve issues
cramps
sprains / strains
swelling
bursitis
arthritis

gout
allergies (incl: oils/perfumes)
varicose veins blood clot or phlebitis
stroke
blood pressure issues
heart issues
skin disorders
seizures

cancer
diabetes
implants
sunburn
inflammation or infections
fever
pain
open cuts, bruises, burns
contagious conditions

Other Issues:



I understand that massage is a health aid and does not take the place of a physician’s care and no diagnosis will be made.

If I am unable to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance. If I miss a scheduled appointment without giving 24 notice, I agree to pay any missed appointment charge.

I am responsible to pay for your massage fees at the time of service. I understand that my insurance company may cover massage and I will submit and manage this process myself.