Tea Spa Wellness Center Massage Intake Forms
Thank you for choosing Tea Spa Wellness Center, and filling the intake forms electronically. It saves paper and benefits the environment. Your input will be put into a PDF file and you will receive a copy by email.
Your Last Name
Your answer
Your First Name
Your answer
The Date of Your Appointment
put N/A if your appointment has not been finalized.
Your answer
Your Street Address
Your answer
City/State/Zip:
Your answer
Your Birthday
Your answer
Cell Phone Number
Your answer
Occupation
Your answer
Would you like to receive promotions and birthday gifts via email?
Have you ever received a Professional Massage
If yes, what is the freqency?
put N/A, if never
Your answer
When is your last massage?
put N/A, if never
Your answer
What results do you want from massage sessions today?
Your answer
Desired Pressure
Prioritize the areas of your body that you would prefer to be massaged
Your answer
Please check the areas of your body that you DO NOT give permission to receive massage.
Required
List stress reduction and excercise activities. Include frequency
Your answer
How oftern do you stretch?
Your answer
Areas you feel tightest in your body?
Your answer
Please list any recent injuries, illness and surgeries.
Your answer
Are you currently under the care of a physician?
If yes, please explain.
Your answer
List any medication you are taking, including over the counter.
Your answer
Please check any that applies.
Required
Do you have any chronic or frequent pain?
Your answer
Are you pregnant?
If yes, how far along are you.
put N/A if not pregant.
Your answer
Please read the paragraph and type your name as a signature.
The above information is accurate and the true to the best of my knowledge. If there are any changes in my current level of health, I will inform the proper health care providers of my condition. I understand that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy. If, for any reason cancellation is necessary, I will give a 24-hour notice. I understand that if I do not give this notice, I will be charged for the appointment unless it can be filled. Emergency cancellations will be determined by my therapist.
Your answer
The Date of Today
Your answer
Your email address
Your email address will not be sold to third party. You will receive a copy of this intake form by email. You will receive promotional emails only if you agreed in Question 9
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms