Before any service can be performed, we ask all customers to please fill out the form below and fill it out prior to arrival. We thank you and look forward in seeing you soon. Name(Required) First Last Phone(Required)Date of Birth:(Required) MM slash DD slash YYYY Email:(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Referred by:(Required) Emergency Contact(Required) First Name Last Name Emergency Contact Number(Required)General & Medical InformationOccupation:(Required) Height:(Required) Weight:(Required) Gender Female Male Are you in good health?(Required) Yes No Age: Any change to your health in the past year?(Required) Yes No Please explain health changes… Physician: If you answer "yes" to any of the following questions, please explain as clearly as possible in the space provided.Do you suffer from acne? Yes No Do you suffer from allergies? Yes No Do you have a pacemaker? Yes No Do you have arthritis? Yes No Are you currently being treated by? Yes No Do you have high blood pressure? Yes No Physicians for any condition? Yes No If yes, what medication are you taking? Please explain medications… Any other medical condition I should know about? Do you suffer from epilepsy or seizures? Yes No Taking medications (including non-prescription)? Yes No Birth Control Pills Yes No Diuretics Yes No Vitamins/Supplements Yes No Do you have any contagious diseases? Yes No Hormone Therapy Yes No Do you have heart disease? Yes No How much water do you drink a day? Do you have asthma? Yes No Have you ever had surgery? Yes No Have you ever had or currently have cancer? Yes No Do you exercise regularly? Yes No Please explain exercise… Describe your overall level of stress? Low Medium High Do you suffer from a blood disorder? Yes No What is your goal for this visit? A monthly or by monthly massage visit Are you pregnant or nursing? yes No Please explain… What kind of massage(s) are you looking for? Relaxing Massage Distress Massage Membership Package of 6 Membership Package of 12 Please take a moment to carefully read the following information you have provided and sign where indicated. If you have a specific medical condition or specific symptoms, certain massage or esthetic treatments may be contraindicated. A referral from your primary care provider may be required prior to services being rendered. If I experience any pain or discomfort during this session I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my comfort level. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Client Signature: Date: MM slash DD slash YYYY Practitioner Signature: Date: MM slash DD slash YYYY CAPTCHA