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Home
About Us
Services
Facials
Massage
Waxing
Massage Packages
Holistic Health
Permanent Makeup
Lift & Tint
Body Treatments
Threading
Lash Extensions
Spa Day Packages
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
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