WE WANT YOUR MASSAGE EXPERIENCE WITH US TO BE AMAZING
Sharing the information below will enable us to make that happen
Name
*
Name
First Name
Last Name
Emergency Contact
Emergency Contact Phone
Emergency Contact Phone
(###)
###
####
Have you had professional massage before?
Yes
No
If yes, when was your last session?
If yes, when was your last session?
MM
DD
YYYY
Do you have any difficulty laying on your front, back or side?
Yes
No
If yes, please explain
Do you have any allergies to lotions, oil or other substances?
Yes
No
If yes, please explain
Do you have sensitive skin?
Yes
No
Are you wearing
Contact Lenses
Dentures
Hearing Aid
Do you sit for long periods of time at
a workstation
a computer
driving
If yes, please explain
Do you perform and repetitive movement in your work, sport or hobby?
Yes
No
If yes, please explain
Is there a particular area of your body where you are experiencing stiffness, pain, tension or other discomfort?
Do you have any particular goals in mind for this massage session?
Thank you!
