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.

Please enable JavaScript in your browser to complete this form.

Name *

Address *

how If Phone

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?

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.

Submit