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Massage Intake Form

PERSONAL INFORMATION

Birthday
Month
Day
Year

MEDICAL INFORMATION

Are you taking any medications?
Yes
No
Are you currently pregnant?
Yes
No
Do you suffer from chronic pain?
Yes
No
Have you had any orthopedic injuries?
Yes
No
Please indicate any of the following that apply to you:
Have you had a professional massage before?
Yes
No
What pressure do you prefer? (If you prefer deep pressure you MUST book with a deep pressure therapist. Light/Medium therapists will NOT be able to deliver deep pressure. Check therapist bios.
Do you have objections to any of the following treatment modalities that may be applied at therapist discretion?
Do you have any allergies or sensitivities?
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