NEW CLIENT INTAKE FORM Please enable JavaScript in your browser to complete this form. - Step 1 of 2Name *FirstLastLayoutPhone *Email *Birthdate (Format xx/xx/xxxx) If You Are Under 18 You Will Need A Signed Consent Form By A Parent or Guardian *LayoutBody Size (For Setup Purposes Only)PetiteSmallMediumLargeX-LargeXX-LargeXXX-LargeXXXX-LargeTable Covering Preferred (Room Can Be Cool)Sheet & Blanket & Table WarmerSheet & Table WarmerTowel & Table WarmerSheet & BlanketSheet OnlyTowel OnlyGlute Muscle Work Consent *Yes, Over Sheet (Covered)Yes, Direct Contact (Uncovered)Unsure, We Can DiscussNoInterested in Dry Skin Brushing? (Prior to Massage)YesUnsure, We Can DiscussNoFace Massage Desired?Yes, AlwaysYes, But Ask Each SessionUnsure, We Can DiscussNo, But Ask Each SessionNo, NeverIs a Breast/Chest Pillow required?NoYesInterested in CBD Products?YesUnsure, We Can DiscussNoNextWhat Line Of Work Are/Were You In? (To Help Determine Repetitive Movements) *Do You Smoke? (If Yes, Please Do Not Smoke Right Before Your Massage)YesNoAre You On ANY Medications? If So Please List Below.Do You Have ANY Allergies?What Is Your Main Area Of Concern For This Appointment?Do You Have ANY Areas To Avoid?Have You, Yourself, Tested Positive For COVID Or Have You Been Around Anyone Testing Positive for COVID In The Last Week?NoYesIs There Anything Else You'd Like Me To Know? Recent Surgeries/Injuries? PreviousSubmit
