CLIENT ONLINE INTAKE FORM - BEST FOR YOU MASSAGE, L.L.C.

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BEST FOR YOU MASSAGE, L.L.C.

WELCOME!
ABOUT THE THERAPIST
WHAT TO EXPECT!
SERVICES OFFERED
BROWSE PRICES/PURCHASE MASSAGE
BOOK AN APPOINTMENT
CONSENT FORM
GET A FREE MASSAGE!
CONTACT US
NEWSLETTER SIGNUP
VISIT OUR BLOG
CLIENT ONLINE INTAKE FORM
HOLIDAY GIFTCARDS ARE HERE

WELCOME!
ABOUT THE THERAPIST
WHAT TO EXPECT!
SERVICES OFFERED
BROWSE PRICES/PURCHASE MASSAGE
BOOK AN APPOINTMENT
CONSENT FORM
GET A FREE MASSAGE!
CONTACT US
NEWSLETTER SIGNUP
VISIT OUR BLOG
CLIENT ONLINE INTAKE FORM
HOLIDAY GIFTCARDS ARE HERE

CLIENT INTAKE FORM

PLEASE COMPLETE PRIOR TO YOUR FIRST VISIT.
The following information will be used to help plan safe and effective massage sessions. Click on arrows to make a choice and blanks without arrows allow a typed response. QUESTIONS WITH RED ASTERISK ARE REQUIRED. *
Please answer the questions to the best of your knowledge. Please ask for assistance if needed. CLICK on SUBMIT Button when completed.

* Indicates required field

First Name *

Middle Initial *

Last Name *

DATE OF BIRTH *

Email *

How did you hear about us: *

Phone Number *

GENDER *

AGE *

Address *

Line 1

Line 2

City

State

Zip Code

Country

CURRENT WEIGHT IN POUNDS *

HEIGHT FT/INCH *

TYPE IN FEET AND INCHES

Are you taking any medications? *

Yes No

If so can you list them or bring in a list? *

EVER HAD A PROFESSIONAL MASSAGE? *

YES NO

IF YES, HOW OFTEN? *

DO YOU EXPERIENCE STRESS IN ANY ASPECT OF YOUR LIFE? *

YES NO

IF YES, HOW DOES THAT STRESS EFFECT YOU? *

DO YOU CURRENTLY SEE A CHIROPRACTOR *

YES NO

IF YES, HOW OFTEN? *

DO YOU HAVE PROBLEMS LYING IN ANY OF THESE POSITION? PLEASE CHECK IF SO. *

DO YOU HAVE ANY MEDICATION ALLERGIES? IF SO, PLEASE LIST. *

DO YOU HAVE ANY ALLERGIES TO OILS, LOTIONS, OR OINTMENTS? *

OILS LOTIONS OINTMENTS

DO YOU SIT FOR LONG HOURS AT A WORKSTATION, COMPUTER, DRIVING, ETC? *

YES NO

IF YES, PLEASE DESCRIBE. *

DO YOU PERFOR REPETITIVE MOTION DAILY OR OFTEN?Choose One *

YES NO

IF YES, PLEASE EXPLAIN. *

DO YOU HAVE ANY MEDICALS IMPLANTS? *

YES NO

IF YES, PLEASE EXPLAIN. *

HAVE YOU HAD A MASTECTOMY? IF YES PLEASE SPECIFY: *

DO YOU HAVE SENSITIVE SKIN? *

YES NO

ARE YOU WEARING CONTACTS? *

YES NO

ARE YOU WEARING CONTACTS? *

YES NO

DO YOU EXPERIENCE PAIN OR DISCOMFORT? *

YES NO

IF YES, PLEASE EXPLAIN. *

PLEASE CHECK ANY OF THE MEDICAL PROBLEMS YOU MAY HAVE: *

PLEASE EXPLAIN ANY CONDITION CHECKED ABOVE. *

ARE YOU CURRENTLY UNDER MEDICAL SUPERVISION? *

YES NO

IF YES, PLEASE EXPLAIN. *

Submit

We Would Love to PROVIDE THE BEST MASSAGE FOR You!

WRITE US A REVIEW

Hours

BY APPOINTMENT ONLY
BOOK AN APPOINTMENT NOW

Telephone

Email

leahfitzgerald@best4youmassage.com