You may print this page and fill in the form to bring with you to your first appointment.  This will save a few minutes before your session which means more massage for you!  That's a good thing.

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First & last name:
Date of your session:
Address, City, State, Zip:


Best way to reach you during the day:
Best way to reach you during the evening:

Have you had professional massage or bodywork before?

Have you had any surgeries or injuries recently?

Do you have any specific problems (recent, current, or chronic) with any
of the following:   (If yes, mark and then explain in space below)

Nervous System_____ Muscles_____ Immune System_____ Heart or Circulatory System_____ Varicose Veins or Blood Clots_____ Bones or Joints_____ Skin Sensitivities or Allergies_____ Illness, Medical Disorder, or Disease_____




Are you currently under medical or chiropractic care?

Are you taking any prescription medication for pain/inflammation?

If you are female, are you pregnant?

Please read the following as well as my Therapists Policies and sign below stating that you understand and agree to abide by them.

~I understand that a massage therapist does not diagnose illness, disease, or any other physical or mental disorder.  I understand that massage therapy is not a substitute for medical or chiropractic treatment.

~I understand that therapeutic massage is provided to enhance relaxation, reduce muscle tension and associated pain, improve circulation & range of motion, and to provide a positive experience of touch.  I have informed the massage therapist of all known physical/medical conditions and medications & I will keep her updated in future visits if there are any changes.

~I have read the above statements as well as the Therapists Policies.  I understand them and agree to abide by them.

Signature:

Date: