Personal Information
First and Last Name*
Phone Number*
Would you like SMS to confirm appointments?*
Email Address*
Date of birth*
Occupation*
Address*
City*
How were you referred to us?*
Massage / Medical Information
Emergency Contact Name*
Phone Number*
Have you ever had a professional massage before? *
If yes, how often do you receive massage therapy?
If yes, do you have a style or pressure preference?
Check all that apply.
Do you wear contact lenses?*
Do you exercise regularly?*
If so, what type(s)?
Are you sensitive to fragrances or perfumes?*
Do you suffer from chronic or persistent pain/discomfort?*
If so, for how long?
What are your common areas of pain or tension?
Any accidents, injuries, or surgeries in the last two years? Please specify.*
Please indicate any conditions that you have had or currently have: (please check the following
that apply)
Check all that apply.
Do you see a chiropractor?*
If so, how often?
Are you currently under medical care?
*
Are you currently taking any prescription medication? If so, for what?
By entering your name, date and signature below, you are effectively providing your signature,
indicating that all the information on this form is true and accurate, to the best of your
knowledge.
Informed Consent and Massage Policies