Name * First Name Last Name Email * Phone * (###) ### #### Where do you prefer to have your massage? * At my Home Brooklyn (217 E Street) Manhattan (151 W 30th Street) Not sure yet Address (only if you want to book a house call) Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name + Phone Number Have you had a therapeutic massage before? * YES NO Are you currently under the care of a Physician and/or Chiropractor? * Please list any injuries and/or surgeries: * Please list any allergies and/or sensitivities * Please list all medications you are currently taking: * Please check all that apply: * Headaches/Migraines Jaw Clenching/Grinding Varicose Veins Neck Pain Seizures Diabetes Back Pain High Blood Pressure Low Blood Pressure Numbness/Tingling Arthritis Sprains/Strains Heart Condition Blood Clots Chronic Pain Fatigue Pregnancy Depression Eating Disorder None Other Please list any areas you do not want worked on by the therapist? (face, feet, abdomen, etc.) * What kind of pressure would you prefer? Soft/Light touch Medium/Firm touch Strong/Deep touch Signature * The information I have provided is accurate and true. I have stated all my known medical conditions and I will take it upon myself to keep the massage practitioner updated on my physical health. I understand that this work does not constitute medical treatment. By signing this release, I hereby waive and release my therapist from any and all liability, past, present and future relating to massage therapy and bodywork. Thank you!I am looking forward our session!
