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Massage Consultation Form

Please fill in before you attend your appointment

Personal Information

Medical Information

Are you taking any medications
No
Yes
Are you currently pregnant?
No
Yes
Do you suffer from chronic pain?
No
Yes
Do you have any orthopedic injuries?
No
Yes
Please indicate any of the following that apply to you

Massage Information

Have you had a massage before
No
Yes
What type of massage are you seeking?
Sports
Hot Stone
Lymphatic Drainage
Deep Tissue
Natural Lift Face
What pressure do you prefer
Light
Medium
Deep
Do You Have any allergies/sensitivities?
No
Yes
Any areas you do not want massaged (feet, face, abdomen, etc.)
No
Yes
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