top of page
BOOK AN APPOINTMENT
Massage Intake Form
PERSONAL INFORMATION
First name
Last name
Phone
Birthday
Month
Month
Day
Year
Email
Occupation
Emergency Contact
*
Emergency Contact Relationship
*
Emergency Contact Phone
*
How did you hear about us? (if someone referred you please type their name below so we can thank them!
*
MEDICAL INFORMATION
Are you taking any medications?
*
Yes
No
If yes, please list name and use:
Are you currently pregnant?
*
Yes
No
If yes, how far along:
Any high risk factors?
Do you suffer from chronic pain?
*
Yes
No
If yes, please explain:
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?
*
Yes
No
If yes, please list:
Please indicate any of the following that apply to you:
*
Cancer
Headaches/Migranes
Arthritis
Diabetes
Joint Replacement
High/Low Blood Pressure
Neurotherapy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
None of the above
Explain any conditions you have marked above:
Are there any other conditions that not listed above?
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.
*
Light
Medium
Deep
Do you have objections to any of the following treatment modalities that may be applied at therapist discretion?
*
Heat/hot stones
Cupping (may leave discoloration on skin)
Aromatherapy
Stretching
All of above are fine with me!
Other - please discuss at appointment
Do you have any allergies or sensitivities?
*
Yes
No
Not Sure
If yes, please explain:
What are you goals for this treatment session?
*
Our cancellation policy is listed on the Locations tab, please read it and type "yes" to confirm that you agree with our cancellation and no-show terms: https://www.kineticrestorationva.com/termsandconditions
*
CUSTOMER SIGNATURE: By signing below, I agree that all the information above is true.
*
Sign in the box or use the keyboard to type.
Signature field is empty.
Upload Image
Submit
Home
Book Now
About
Packages & Memberships
Gift Card
Blog
Careers
bottom of page