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Massage and Body Treatment Form
Date of Appointment
*
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Cell Phone
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Alternate Phone
Address
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Street Address
Address Line 2
City
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State
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Email
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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?
*
Yes
No
If Yes, How Recently?
Do you have a medical condition or injury we should be aware of?
*
Yes
No
If Yes, Please Describe/Explain
Are you currently being treated by a physician for any condition?
*
Yes
No
If Yes, Please Describe/Explain
Are you currently taking any medications (including non-prescription drugs)
*
Yes
No
If Yes, Please List
Please list any known Allergies (if any)
Are you currently pregnant?
*
Yes
No
What Is Your Due Date?
Date Format: MM slash DD slash YYYY
Do you have any areas you would like us to avoid?
*
Yes
No
If yes, please specify/describe
Do you have tension or soreness in a specific area?
*
Yes
No
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.
{Appointment.FirstServiceName}
Client State
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Birthday (M D YY)
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{Client.SmsOptInStateEnum}
Client Text Notification Opt-in
{path=Appointment.AppointmentDateLong,format=d} {path=Appointment.AppointmentTime,format=d}
Are you currently pregnant?
No
Yes
Are you currently taking any medications (including non-prescription)?
Yes
No
Are you currenty being treated by a physician for nay condition?
Yes
No
Do you have a medical condition or injury we should be aware of?
No
Yes
Do you have any areas you’d like us to avoid?
No
Yes
Do you have tension or soreness in a specific area?
Yes
No
Emergency contact
Emergency contact phone:
Have you ever had a professional massage before?
No
Yes
If yes, how recently?
If yes, please describe/explain.
If yes, please describe/specify
If yes, please describe/specify.
If yes, please list.
If yes, what is your due date?
Please list any known allergies (if any).
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