Massage Intake 

For Returning Clients

Name *
Name
Phone
Phone
Date Requested
Date Requested
Time Requested
Time Requested
Current Medical Conditions
If you have a specific medical condition or specific symptoms, massage, bodywork may be contraindicated. A referral from your primary care provider may be required prior to services being rendered.
I understand that massage is designed for the purpose of relaxation and relief from tension, muscle spasms, or poor circulation. The massage therapist cannot diagnose medical issues / diseases / disorders or perform spine palpitations. *