978-650-2895 | 978-244-0300

3 Littleton Rd Unit 1 | Westford, MA 01886
Westford/Chelmsford Line
(Formerly Of Chelmsford)

Please check Appointment Guidelines link before coming to your appointment it will help you understand the new procedures we need to follow.

A Spa to Remember Massage Therapy Consent Form

    Personal Information

    First and Last Name*
    Phone Number*
    Would you like SMS to confirm appointments?*
    Email Address*
    Date of birth*
    Occupation*
    Address*
    City*
    State*
    Zip Code*
    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?

    Payment Information

    We require a 24-hour cancellation notice or appointment rescheduling of all services.
    A Charge of 50% of the service will be incurred for all missed appointments.

    Please note that this card will only be charged in the case of a same-day cancellation or a no-show appointment, please bring in a separate payment method at the time of your service.

    Type of card*
    Name on Card*
    Card Number*
    Expiration Date*
    CVC Number*
    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

    Privacy Policy - All written records and massage sessions are kept strictly confidential and will not be shared with any outside establishment. individuals. organizations. or medical facilities without explicit written consent from the client (you) or the clients legal guardian. Unless legally required by local, state, or federal subpoena, summons, or other coon order.

    Would you like to receive weekly texts of our specials?

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