Client Lookup

Please locate your account:

First Name

Last Name

Email

Profile Set Up

First Name *

Last Name *

Phone *

Email *

Birthday *

How did you hear about us? *

Address *

City *

State / Province / Region *

Postal Code *

Country *

Emergency Contact

First Name *

Last Name *

Phone *

Massage Intake Form

First massage ever? *

Yes

No

Date of last spa treatment

Describe

Exercise Frequency:

Exercise Types:

Goals for therapy today:

List and prioritize your current symptoms/issues: (stress, injuries, pain, stiffness, numbness/tingling, swelling, etc.)

Pregnant or recent delivery? *

Yes

No

High-Risk? (multiples, gestational diabetes, preeclampsia, HBP, etc) *

Yes

No

Medical History

Are you currently under the care of a specialist? *

Yes

No

If so, please specify

List medications/vitamins/supplements taken regularly

Do you have any of the following conditions/practices?

Cold/Flu

Eczema/Psoriasis

Edema

Varicose veins

Arthritis/Osteoporosis

Numbness/Tingling

Fibromyalgia

Headache/Migraine

Epilepsy/Seizures

Vertigo/ Dizziness

Scoliosis

Endocrine/Thyroid

Inflammation

Diabetes

Cancer

Kidney disease

Pacemaker

Stroke/Heart Condition

High/Low Blood Pressure

Recent surgery

Fractures/Broken Bones

Injuries

Hernia

Hearing aids

Handicap needs

Skin Cuts/Sores/Burns/Bruises/Rash/Infection

Neurological Disorder

Allergic to:

Algae/Seaweed

Sulfur

Nuts/Seeds

Scents/Smells

Other

Massage and bodywork therapy practices are designed to promote and maintain the health and well-being of the client. These therapies do not include the diagnosis of illness, disease, impairment or disability. If I experience any reactions, pain or discomfort during this session, I will immediately inform the therapist so that the products, pressure and/or manipulations may be adjusted to my level of comfort. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all my known medical conditions and will keep the therapist updated as to any changes in my medical condition.

By signing below, I acknowledge that I have read the above information and give my consent to be treated. This consent form is valid for future treatment, but I will alert the staff is there are any future changes to my medical history. Thank you for completing this questionnaire; by doing so, your therapist can give you the most personalized and effective treatment possible. Your privacy, including the information on this form is strictly confidential, and will not be shared without your permission.

* By signing, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By signing here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

January 17, 2021