Name *
Phone (Cell Preferred) *
Phone (Cell Preferred)
Date of Birth *
Date of Birth
Please describe your job title and daily activities. i.e. Sitting, Standing, Walking, Riding, etc.
Name, Number & Relationship
Name & Number
How often do you need to receive Massage Therapy? This will be discussed further concluding your first massage reservation.
How do you fill your inner well?
Where are they stored and what sensations do you notice in those areas?
Activity level, current areas of interest.
Do you have any of the following conditions? Respiratory Cardiovascular Skin Head and Neck Infectious Pregnancy or Gynecological Soft Tissue Joint Dysfunction Family History Allergies/Sensitivities Neurological Car Accidents Surgeries
Please include dosing information
Waiver *
Client Waiver Form Please take a moment to read and initial the following information: I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. I affirm that I have notified my therapist of all known medical conditions and injuries. I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. I understand that massage is entirely therapeutic and non-sexual in nature. I understand that I will be charged up to the full price of my massage if I cancel within 48 hours of my scheduled reservation.