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.