Consultation form

Your path to holistic healing begins here. This confidential consultation form helps us customize your massage experience, ensuring your safety, comfort, and optimal therapeutic results.

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Name *

Address *

Phone *

Emergency contact *

Emergency contact phone *

Therapist *

How did you learn about us? *

Have you received massage therapy or bodywork before? *

• Yes
• No

Are you on any medication? *

• Yes
• No

If yes, which ones?

Do you exercise? *

• Yes
• No

If yes, how many times per week?

How many hours?

to you Emergency

Please indicate which of the following conditions apply to you *

• Neck injury
• Alcohol within 24hrs
• Recent surgery
• Pregnancy
• Kidney alignment
• Open wounds
• Emotional changes
• Sports injury
• Osteoporosis
• Sinus congestion
• Phibitis
• Chronic pains
• Headaches
• Bruises
• Blood clots
• Flu
• High blood pressure
• Fever within 24hrs
• Cold virus
• Varicose veins
• Wear contacts
• Allergies (almond jar)
• Acute pain
• NO CONDITIONS

Client Agreement for Massage Treatments *

• I understand that massage is for the purpose of stress reduction, relief from muscle tension or pain, or for increasing circulation. I understand that massage does not prescribe medical diagnoses or disease, or any other physical or mental disorder. The massage therapist does not practice direct treatment nor perform spinal manipulations. I will inform the therapist of my current condition at the time of each visit.

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