Peaceful Nature Massage: Health and Contact Information Form
Thank you for choosing Peaceful Nature Massage, Inc. for your therapy services. By entering your name and submitting this form you are acknowledging that you have read the text below and have listed any relevant personal information truthfully and to the best of your ability.
We are a professional massage clinic and want to portray that in all aspects of our business. We only hire professionally licensed massage therapists (LMT). If you would like verification on any of our LMTs please ask the front desk staff to show you a copy of their license. Our LMTs will use proper draping at all times; women’s breasts and male and female genitalia will not be exposed or massaged at any time. If during your session you feel uncomfortable, ask your LMT to end the session immediately. If you do not feel we have upheld high standards please let us know so we can make changes.
It is your responsibility to let the LMT know of any pre-existing conditions, specific sensitivities or limitations, and to inform your therapist if you feel any discomfort during your session. If you do experience discomfort, please ask the LMT to adjust the level of their pressure. You understand and voluntarily accept any risks associated with your massage or any use of our facility and agree that Peaceful Nature Massage, Inc. will not be liable for any injury, including, without limitation, personal, bodily or mental injury, economic loss or any damage to you resulting from negligence or other acts of the company or anyone on the company’s behalf or anyone using the services of the facility of the company.
Please note we have a 12 hour cancellation policy. If we do not have 12 hour notice of a cancellation of an appointment you will be responsible for the cost of the missed appointment.
If you are under the age of 18, you are required to have a parent or guardian accompany you to your first appointment to submit written approval, unless otherwise authorized.
Thank you for your time! Please call (319) 337-0476 with any questions or concerns.
Birthday (please provide birth year):
How often do you receive massage therapy?
Every 1-2 weeks
Every 4-6 weeks
A few times a year
I have never had a massage
What is your desired pressure?
Please check the following conditions that apply to you:
Back or neck problems (explain below)
Carpal tunnel/cibital tunnel
Skin problems: acne, athlete's foot, open sore or cut, rash, etc.
High blood pressure
Low blood pressure
High blood sugar
Low blood sugar
Currently pregnant (If yes, indicate below how far along you are)
Additional information on any items selected above:
Medications (please list):
Surgeries (please list, include date):
Do you exercise? How often?
What do you like to do in your free time?
Is there anything else you'd like us to know before your appointment?
Emergency contact (please include name, relationship to you & phone number):
City, State, Zip Code:
Primary phone number:
Secondary phone number:
How did you hear about Peaceful Nature Massage?
Friend, family or coworker
If you were referred by a friend, family member or coworker, please write their name below. They will receive a coupon for $15 off a massage!
I have read the information at the top of this form and answered all relevant questions fully and truthfully.
Send me a copy of my responses.
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