Electronic Massage Form - Rosewater Spa & Wellness

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About Us
Services
Pricing
Policies
Shop
Forms
FAQ
Contact Us

Massage Form

Name*

Phone*

Email*

Birthday*

Mailing Address*

City*

State*

Zip*

Emergency Contact*

Emergency Contact Phone Number*

Have you ever received massage therapy before?*

Yes No

If yes, what type?

Are you taking any medications? If so, please specifiy*

Do you have a history of any of the following? Please mark ALL that apply:*

Varicose Veins Abdominal Pain Disc Problems Allergies to oils/perfumes Broken Bones Carpal tunnel syndrom High blood pressure Frozen shoulder Nervous tension Fibromyalgia Heart attack Arthritis Stroke TMJD Headaches Sprains Accident Neck pain Back pain Whiplash Cancer Diabetes Surgery

Are you pregnant?*

Yes No Not applicable

If yes, how many weeks?

Please check the following:*

I understand that massage is not a replacement for medical care and that no diagnosis will be made. I understand that I am full in control of my massage session and can terminate it at any time and for any reason

Send

Name *

Email *