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Massage Intake Form

By signing below, you agree to the following.

I have completed this form to the best of my ability and knowledge and agree to inform my Massage Therapist of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the business for any injury or damages incurred due to any misrepresentation of my health history. I understand if I am a no-show or last minute cancellation, I will be charged full price. I will arrive 10 minutes before my scheduled time appointment to insure the full service time.

Today's Date: November 14, 2024



First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
First Client's Signature*
Second Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Third Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Fourth Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Fifth Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Sixth Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Seventh Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Eighth Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Ninth Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Tenth Client's Name

First Name*

Middle Name

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

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Do you have a Gift card or Gift certificate?
Gift card or Gift certificate information*
No
Yes

If yes, how much is the gift amount? *
Emergency Contact Information

Emergency Contact *

Relationship *

Phone *
Additional Information

How did you hear about us? *
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Health Information 

Are you taking any medications?*
No
Yes

If yes, please list name and use
Are you currently pregnant?*
No
Yes

If yes, how far along?
Any high risk factors?*
No
Yes

Please explain
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please explain
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
Neuropathy
High/Low Blood Pressure
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above

Massage Information 

Have you ever had a professional massage?*
No
Yes

When?
What type of massage are you seeking?*

If Other, please explain
What pressure do you prefer?*
Do you have a gender preference for your therapist? Note: a request for a male therapist needs advance notice.*
Do you have any allergies or sensitivities?*
No
Yes

Please explain

Please indicate any areas of discomfort

What are your goals for this treatment session? *
UPGRADES: ESSENTIAL OILS, HOT STONES *
CBD Full Body $25
CBD Spot Treatment: $10
Essential Oils: $10
Hot stones $25
Ayurveda Experience hot oil scalp massage $25
Choose any 3 options for $50
No upgrade
HANDS AND FEET UPGRADE: *
Sugar hands and feet Scrub: $25 (hands and feet)
Choose any 3 options for $50
No upgrade
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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