1st Time Client Form

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Information I need to provide the best massage experience for you.

This form is only completed one time.

Email *

First & Last Name *

Phone Number *

Birthday *

YYYY

Home City

Your Height and Weight - My massage table can support up to a 350lbs capacity and is 2.5ft wide x 7ft in length (incl headrest). *

Under/Shorter

Over/Taller

300lbs

6ft

Vision *

20/20 - Don't need glass/contacts

Glasses / Contact Lens

Required

Do you smoke? If so, how often? *

Other:

Emergency Contact *

Name, Phone#, Relation

Assurance *

All information provided in this form is keep safe/protected, never shared, and handled with the utmost confidentiality!!!

Acknowledged

Required

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