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Well Life Massage Intake 

Massage Therapy consists of many modalities including but not limited to lymphatic/MLD, Assisted Stretch Therapy, Deep Tissue/DT, Swedish, Cranio Sacral, Myofacsial Release, Reflexology, and more. The importance of your medical history and current condition is important to your wellbeing as the therapist uses their knowledge and customizes the massage to your needs. Communication is the key to receiving the most benefit from your therapy. If at any time you are uncomfortable, feel pain or want to end your session, please let the therapist know. We are here to help you achieve the best results from your therapy. 

Please understand that if you are requesting lymphatic massage for enhancement or cosmetic surgery, you must abide by physicians orders during your massges.  You must also pay in advance for a package of six treatments.  If you miss a treatment without cancelling before the 24 hour period, you will lose that visit.


Client

By signing below, you agree to the following: I have been advised of the policies and procedures pertaining to massage and I understand these policies. Information regarding massage in general, benefits, contraindications of massage, and possible alternative therapies have been explained to me. I further understand that massage therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the massage should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken. 

Date Signed: May 7, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Third Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Fourth Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Fifth Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Sixth Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Seventh Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Eighth Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Ninth Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Tenth Participant's Name

First Name*

Middle Name

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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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

Preferred first name

Home phone

Mobile phone

email *

Referred by
Are you taking medications?*
No
Yes
Are You Allergic to :oils, lotions, nuts, fruits, scents or other things you might come into contact with while getting a service?*
No
Yes
Are you pregnant?*
No
Yes
Are you you currently under medical supervision or receiving other medical interventions?*
No
Yes
Do you have any of the following? Please check.
Areas of Swelling
AutoImmune Disorders
Back/Neck Problems
Bleeding Disorders
Blood Clots
Bruise Easily
Bursitis
Cancer
Contagious Condition
Decreased Sensation
Diabetes
Fibromyalgia
Headaches
Heart Condition
Hypertension
Kidney Disease
Multiple Sclerosis
Neurological Condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendonitis
TMJ Disorders
Vericose Veins
Vertigo/Dizziness
Areas of broken skin?*
No
Yes
History of joint replacement surgery?*
No
Yes
Recent injuries or medical procedures in the last two years?*
No
Yes
Any other injuries or health conditions?*
No
Yes
Have you had massage before?*
No
Yes
Reason For Massage*
Relaxation
Specific Problem
Other

If "Other", please specify
How Much Pressure do you prefer for your massage?*
Light
Medium
Firm
Not Sure
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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