Yomassage Intake Form
This is your time of luxury and self care.
Email address *
Date of your selected Yomassage session: *
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Would you like to receive the occasional email to update you about future Yomassage sessions?
Full Name *
Your answer
Date Of Birth *
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Email *
Your answer
Phone Number *
Your answer
Emergency Contact/Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
How did you hear about us? *
What pressure do you prefer? *
Are there any areas you do NOT want massaged *
Required
Check the areas that need extra attention *
Required
Please indicate any condition that you have had or currently have: *
Required
Please explain any condition you marked above:
Your answer
By e-signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. *
Your answer
If client is under 18 years of age a parent or legal guardian must fill out the form and e-sign below:
Your answer
Date of E-Signature *
MM
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