Massage Client Intake
Please take a minute to fill in the following info to ensure your best experience and outcome with our services.
First Name
Last Name
Email
Phone Number
Medical Questions
Are you currently taking any medications - prescriptions or over-the-counter?
Are you currently pregnant?
Yes
No
Do you suffer from chronic pain?
Yes
No
Health History
Have you ever worked with a massage/healing professional?
Yes
No
Please describe your experiences, and your goals working together.
What kind of pressure do you prefer?
Please describe your reason for seeking treatment (pain/ discomfort, relaxation, healing, etc.) If for pain, please describe with as much detail as possible.
Do you have any trauma history we should be aware of?
I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not suitable for a medical examination, diagnosis or treatment.
I understand that this is a therapeutic massage and any sexual remarks or advances will terminate this session and I will be liable for payment of the scheduled treatment.
Serenity Spa is currently training massage students through North Star Healing Institute's massage school. Students are required to observe a number of massages. Click here if you are NOT comfortable with a student observing your therapist
Your Signature
*
Clear
I understand that massage therapy should not be performed on persons with certain medical conditions, and I certify that I have truthfully answered all the questions pertaining to medical conditions.
Submit