Massage Consultation Form

Please fill out the following form.

First name

Last name

Email

Phone

Date of birth

Day

Month

Year

Are you taking any medications?

No

Yes

Are you currently pregnant?

No

Yes

Please list medications here

If so, for how long and any high risk factors

Do you suffer from chronic pain?

No

Yes

Do you have any orthopedic injuries?

No

Yes

Explain pain and what relieves it

Please list injuries

Please indicate any of the following that apply to you

I declare that the info I’ve provided is accurate and complete.

Initials

Contact