Massage and Body Treatment Form

Date of Appointment*
Date Format: MM slash DD slash YYYY
Name*
First Last
Cell Phone*
Alternate Phone
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
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?
Date Format: MM slash DD slash YYYY
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
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.