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Massage Intake
A few questions so your therapist knows exactly what you need.
Your name
*
(required)
Email address
*
(required)
Phone number
Date of birth
*
(required)
What do you do for work?
What you'd like
Which treatment?
*
(required)
Select…
Swedish or relaxing
Deep tissue
Sports massage
Aromatherapy
Hot stone
Pregnancy massage
Indian head massage
Reflexology
Where would you like us to focus?
*
(required)
Neck and shoulders
Upper back
Lower back
Hips and glutes
Legs
Feet
Arms and hands
Head and scalp
Full body, evenly
Anywhere you'd like us to avoid entirely?
How much pressure do you like?
1
2
3
4
5
6
7
8
9
10
Very light
As firm as possible
What are you hoping for?
*
(required)
Select…
Relaxation
Relief from specific pain
Recovery after exercise
Better mobility
Help with sleep or stress
Managing an ongoing condition
Your body
Any pain or tension right now?
*
(required)
Injuries or surgery, past or recent
*
(required)
Do any of these apply?
*
(required)
High or low blood pressure
Heart condition
Diabetes
Blood clots or DVT history
Osteoporosis
Arthritis
Fibromyalgia
Recent fracture
Skin condition
Cancer treatment now or recently
None of these
Are you pregnant?
*
(required)
Select…
No
Yes - first trimester
Yes - second trimester
Yes - third trimester
Recently given birth
Medication
Preferences
Have you had a massage before?
*
(required)
Select…
No, first time
Once or twice
Regularly
Anything that helps you relax?
*
(required)
Quiet - no conversation
Happy to chat
Music
Silence
Warmer room
Cooler room
No oil on my hair
Allergies to oils, lotions or nuts
*
(required)
I'll tell my therapist during the treatment if anything is uncomfortable
*
(required)
Leave this field empty
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