Massage Intake Form Name * First Name Last Name Phone * (###) ### #### Email * Zip Code * Is this your first massage? * yes no Do you have a pressure preference for your service(s)? * yes no Are you currently under the care of a physician? Please list any allergies here: Indicate what services you are interested in receiving: 60 min massage 90 min massage Couples massage 60 min facial 90 min facial 60 min body scrub 90 min body scrub 60 min detox wrap 90 min detox wrap 60 min reiki Hair removal service Multiple services Please list any pain, injuries, or areas of focus you would like addressed in your massage: Do you have any specific treatment goals for your session today? Permissions * I give my permission to receive massage therapy and understand that therapeutic massage is not a substitute for traditional medical treatment or medications. I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications and I have clearance from my physician to receive massage therapy. I understand the risks associated with massage therapy and release the company and the individual massage therapist from all liability concerning any injuries that may occur during the session. I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly. I understand that I or the massage therapist may terminate the session at any time. I have been given a chance to ask questions about the massage therapy session and my questions have been answered Thank you! Someone will contact you soon!
