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CONSULTATION FORM

Today's Date: December 2, 2020

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

MASSAGE

1. Have you had a professional massage before?*
No
Yes
2. Do you have any particular goals in mind for this massage session?*
No
Yes

If YES, please specify?
3. Do you have any allergies?*
No
Yes

If YES, please specify?
4. Do you have sensitive skin?*
No
Yes
5. Is there a specific area of the body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If YES, please specify?
6. Are there any areas that should be avoided?*
No
Yes

If YES, please specify areas of concern
7. Are you or could you be pregnant?*
No
Yes

If YES, how far along?
8. Medical History: Do you currently or have you ever had any of the following:
RECENT SURGERY OR INJURY
HEADACHES/MIGRAINES
CANCER
DIABETES
HIGH OR LOW BLOOD PRESSURE
HEART CONDITION
UNDER MEDICAL SUPERVISION
OPEN SORE OR WOUNDS/SKIN CONDITION
9. Are you taking any medication that would affect your session today?*
No
Yes
10. Is there anything else about your health history that you think would be useful for me to know in order to plan a safe and effective massage session for you?*
No
Yes

If YES, please specify?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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