Please call to make an appointment before fill out the application.
Name: *Phone: *
Address: *
Email: *
Alternate Phone:Occupation:Physician:
In Case of Emergency:Phone Number:
It is understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appiontment. ( Please initial: )
Have you ever received a professional massage previously? (Circle One)YES NO How recently?
Do you have or have you ever had canver? (Circle One)YES NO If yes, please provide your therapist an approval from your physician for massage.

General & Medical Information
If you answer "yes" to any of the following questions, please explain as clearly as possible in conments section.
YESNO Do you suffer from frequent stress?
YESNO Are you diabetic?
YESNO Do you have frequent headaches?
YESNO Are you Pregnant?Due Date:
YESNO Do you suffer from arthritis?
YESNO Do you have high blood pressure?
YESNO If answered yes to the previous question,
are you talking medication for this?
YESNO Do you suffer from seizure disorders or epilepsy?
YESNO Do you suffer from joint swelling?
YESNO Do you have varicose veins?
YESNO Do you have any contagious disease?
YESNO Do you have osteoporosis?
YESNO Do you have any allergies?
If yes, please explain:
YESNO Do you bmise easily?
YESNO Have you had any broken bones in
the past 2 years?
YESNO Have you been in an accident or suffered any
serious injuries in the past 2 years?
YESNO Do you have any tension or soreness in any
specific area(s)?
If yes, please explain:
YESNO Do you have vardiac or circulatory problems?
YESNO Do you suffer from back pain?
YESNO Do you have numbness or stabbing pains anywhere?
YESNO Are you sensitive to touch / pressure in any ares?
YESNO Have you aver had surgery?
If yes, please explain:
YESNO Do you have any other medical condition that
we should be aware of?
YESNO Are you currently in any medications?
If yes, please list:

If you have a specific medical condition or specific symptoms, massage may be contraindicated.
A referral from your primary care provider may be required prior to service being provided.
I understand that massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should consult with a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the massage session may be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability of the practitioners part should I fail to do so. I also understand that appointment times include time necessary for dressing and undressing.

Client Signature
Parental Consent for massage / bodywork (if under 18)
Therapist's Signature
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