Massage Therapy Intake Form

PERSONAL DATA PRIVACY ACT OF 1974 (5 U.S.C. 552a)
Message Therapy Intake Form

PERSONAL INFORMATION

First
Last
Address
Address
City
State/Province
Zip/Postal
May we add you to our e-mail list?

HEALTH INFORMATION

(Please select all that apply)
May we contact, if necessary?
Conditions
Regularly Exercise?
Allergies
Medications?
Recent Surgery
Women Only

MESSAGE PREFERENCES

(Please select all that apply)
Shoulders:
Front Neck:
Chest:
Arms:
Hands:
Front of Legs:
Feet:
Back of Legs:
Glutes:
Upper Back:
Lower Back:
Back Neck:
Scalp:
Type of Massage Desired:
Length of Massage:

DESIRED RESULTS

(Please select all that apply)
Treatment

MASSAGE HISTORY

(Please select all that apply)
Have you ever had a professional massage before?
Where
Was your body sore afterwards?

CONSENT AGREEMENT

CANCELLATION POLICY

TREATMENT OF A MINOR

I hereby authorize a Licensed Massage Therapist to perform service of massage therapy for my child/dependent.


A 20% gratuity will be automatically added for spa packages (not spa services).

Missed appointments without 24 hours notice will need to pay 100% for the services missed before future services can be booked.

Due to the high volume of vacation travelers, the sooner you make the reservation, the easier we will be able to accommodate your requests. If you have any questions, please feel free to contact us. Thank you and we look forward to hearing from you.