Digital massage waiver- a helpful assistant in the massage business.

First and Last Name: * Please enter your name.

Date of Birth:

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Email: Please enter your email.

Phone number: Please enter your phone number.

Referred By: Please enter your answer here.

Receive Text Message Appointment Reminders Please check it here.

Receive Email Appointment Confirmations Please check it here.

Receive Emails for discounts and specials Please check it here.

Primary reason for your appointment today? Please enter your answer here.

Are you taking any medications? Please enter your answer here.

Are you currently pregnant?

yes

no

Please select at least one choice above.

if yes how far along ? Any high risk factors? Please enter your answer here.

Do you suffer from chronic pain?

yes

no

Please select at least one choice above.

if yes, please explain. What makes it worse? What makes it better? Please enter your answer here.

Have you had any orthopedic injuries or surgeries?

yes

no

Please select at least one choice above.

If yes, please list Please enter your answer here.

Have you had a professional massage before?

yes

no

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What type of massage are you seeking?

relaxation

therapeutic/deep tissue

Please select at least one choice above.

What pressure do you prefer?

light

medium

deep

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Do you have any allergies or sensitivities?

yes

no

Please select at least one choice above.

If yes please explain Please enter your answer here.

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

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Please Enter Date *

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