Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is there anything we should know about your parking or specific directions?
Phone
*
(###)
###
####
Email Address
*
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
(###)
###
####
Please list any areas of discomfort
Comfort on table
*
Depending on what is going in your body, sometimes you may have various preferences while laying on the table. Please select the statement that best applies to you so that we can prepare with the appropriate comfort measures.
What type of pressure do you prefer for a massage?
What is your goal from receiving bodywork?
*
Please select any health conditions you have
*
If you checked any of the above, please explain
Do you have any known allergies?
*
Yes
No
If yes, please list those allergies
Are you currently pregnant?
*
Yes
No
Currently trying to conceive
If yes, how many weeks?
Have you recently given birth?
Yes
No
If yes, how recently?
In the past 12 months, have you had any injuries?
*
Yes
No
If yes, please list those injuries and the type of treatment you received
In the past 12 months, have you had any surgeries?
*
Yes
No
If yes, please explain
Additional Services
If you selected Kinesiology Taping, please indicate area you wish to have taped
Please list anything else you would like your massage therapist to know prior to the your appointment
