Please fill out all information as accurately and thoroughly as possible.It is the better that you give us what you consider too much information, rather than not give us enough information.
Are you or have you ever had any of the following conditions (Please check yes or no).
  • Smoker? YesNo
    High Blood Pressure? YesNo
    Low Blood Pressure? YesNo
    Epilepsy? YesNo
    Frequent Headaches? YesNo
    Nausea? YesNo
  • Pregnant? YesNo
    Allergies? YesNo
    Seizures? YesNo
    Varicose Veins? YesNo
    Dementia? YesNo
    Skin Conditions? YesNo
  • Contagious Disease? YesNo
    Heart Conditions? YesNo
    Diabetic? YesNo
    Cancer? YesNo
    Frequent Anxiety? YesNo
    Surgeries? YesNo
I attest that the above information is true and accurate to the best of my knowledge
Disclaimer: By signing above, I agree that I understand that a massage therapist is not a doctor and cannot prescribe medication or diagnose medical conditions. The therapists does not discriminate on the basis of race, religion, age, gender and sexual preference.

Which treatment and what areas (e.g. legs) are you interested in having?

What are your goals and expectations of the treatment?
Have you used any of the following in the past 30 days?
Check any of the following that applies too you.