Massage and Body Treatment Form

Date of Appointment*

Name*

First Last

Cell Phone*

Alternate Phone

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Date of Birth*

Occupation*

Referred by (if applicable)

First Last

Emergency Contact*

First Last

Emergency Contact Phone*

Have you ever had a professional massage or spa treatment before?*

If Yes, How Recently?

Do you have a medical condition or injury we should be aware of?*

If Yes, Please Describe/Explain

Are you currently being treated by a physician for any condition?*

If Yes, Please Describe/Explain

Are you currently taking any medications (including non-prescription drugs)*

If Yes, Please List

Please list any known Allergies (if any)

Are you currently pregnant?*

What Is Your Due Date?

Do you have any areas you would like us to avoid?*

If yes, please specify/describe

Do you have tension or soreness in a specific area?*

If yes, please describe/specify

E Signature

I understand that massage and body work are for the purpose of stress reduction, relief of muscular tension, improved circulation and general relaxation and are not substitutes for medical examination or diagnoses. I have stated all known medical conditions and have consulted a medical doctor for stated conditions. I hereby release Jinsei Spa, its staff and Licensed Massage Therapists of any and all liability past, present and future.

First Last

Date

Comments

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Massage and Body Treatment Form

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