Initial Contact and Reservation Request
This is a screening process required prior to making a reservation. The information obtained will be used to create a file & begin your medical history intake.
Email address *
Name: First and Last *
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Birthday: mm/dd/yyyy
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Phone #: *
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Preferred Method of Contact to Schedule your Session: *
Address Where Massage Will Take Place: *
Your answer
Identifying Features of Property: apartment, single family home, color, cars in driveway, etc.) *
Your answer
Additional Instructions: gate/door codes, driving instructions, special entrances, parking suggestions, etc. *
Your answer
Occupation: describe job title, and daily activities, i.e. sitting, standing, walking, riding, etc. *
Your answer
Hobbies/ Lifestyle: activity level, current areas of interest *
Your answer
What Triggers Your Stress Response? *
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Current Self Care Rituals: yoga, exercise, meditation, journaling, etc. *
Your answer
Medical History: injuries, surgeries, pathologies, car accidents, mental illness, emotional trauma, allergies, medications, sensitivities, etc. Please include dates, dosing, current/past treatment, and how it relates to your current goal. *
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Physician Name and Contact info: *
Your answer
Desired Treatment Plan: how often do you need to receive massage treatment? *
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Date/Time Requesting: *
Required
Massage Length: *
Past Massage History: *
Your answer
Any additional information you would like to add:
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A copy of your responses will be emailed to the address you provided.
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