Intake Form

Name *

First

Last

Phone Number *

Email *

Address, City, State, Zip Code *

Have you ever received massage therapy?

• Yes
• No

Type Of Service *

• Swedish Massage (light pressure)
• Signature (medium pressure)
• Deep Tissue, (additional $25, based on availability)
• Hot Stone (Swedish or Signature combined with hot stones)
• Maternity (light or medium pressure)
• Body Scrub
• Body Wrap
• Signature Facial
• Anti-Aging Facial

Length of Service

• 60 Minutes
• 90 Minutes (based on availbility if not requested in advance)

Add-Ons

• Hydrating Anti-aging Mask -$25
• CBD Oil - $25 (helps with anxiety, inflammation and pain)

Table Warmer Preference

• Off
• Low
• Medium
• High

Any medications you are taking and for what reasons?

Any recent surgeries or health conditions we should be aware of?

Areas of focus, explain any areas of injury or pain.

Any areas that you would like us to avoid? (sensitivity, pain, ticklish)

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Phone

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