Massage Intake Form

Client Intake Form

Are you pregnant?*
Please select one option
Have you ever received massage therapy?*
Please select one option
Type of massage experienced:
Please indicate with an (X) the areas you are feeling discomfort

Please indicate your consumption level:

Salt
Sugar
Caffeine
Tobacco
Alcohol
Exercise
Water
Do you have any of the following today?*
Please select at least one option
Have you consumed alcohol in the last 24 hours?*
Please select one option

Please read the following and sign below:

-I understand that this massage is not a replacement for medical care and that to no diagnosis will be made.

-If I cancel my massage less than 24 hours before the scheduled time, I am responsible for 50% of the cost of the massage.

Thank you for taking the time to fill out this form.

Contact Us

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Location

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Office Hours

Last Patient Appointments are at 12:00 pm and 6:00 pm

Westlake Location

Monday:

8:00 am-12:00 pm

3:00 pm-6:00 pm

Tuesday:

3:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

3:00 pm-6:00 pm

Thursday:

3:00 pm-6:00 pm

Friday:

8:00 am-12:00 pm

Saturday:

Closed

Sunday:

Closed