First Name (required)

Last Name (required)

Phone Number (required)

Your Email (required)

How did you hear about us? (required)
Select OneGooglebingFacebookYahooMSNLocal HotelDrove byReferred by a FriendReferred by an EmployeeCoupon

Have you received a massage before? (required)
 Yes No

If "yes" how often?

What is the reason for your massage?

Are there any areas you want me to concentrate on? (required)

Do you prefer a deep or a light massage?

Are there areas you want to avoid being treated?

Are you under the care of a physician or health care practitioner? (required)
 Yes No

If "yes" is indicated, for what?

Are you having any problems we should know about? (required)

Current Conditions:
 Pregnancy Headaches Sleep Disturbances Inflammation Fatigue
 Blood Clots Asthma Easy Bruising Cancer Skin problems Dizziness
 High/Low Blood Pressure Heart Problems Numbness/Tingling Varicose Veins
 Hernia/Ulcer Diabetes Digestive Problems Breathing Problems

Please list any medication you are taking:

Notes!

I understand the massage services are designed to be a health aid and are in no way to take the place of a doctor's care when it is indicated. Information exchanged during any massage session is educational in nature and is intended to help you become more familiar and conscious of your own health status and is to be used at your own discretion.

Emergency Contact (name, phone & relationship): (required)

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