Please assist us in tending to your needs by filling out as much detail as you like in the below form. Other than filling out your name and accepting the terms, you are free to submit only the information you are comfortable with. Please ensure you choose the therapist to whom you would like to send the information.

Name (required)



Email Address


Referred By

Emergency Contact Information



Have you ever had a professional massage before? if so, how often?

How are you feeling today?

Are you, or have you been under the care of a medical doctor, chiropractor, or health care provider? If yes, please explain.

Are you on medications currently? If yes, please list them.

Have you been in an accident or suffered any injuries in the past two years? If yes, please explain.

Do you have any areas of specific pain? If yes, please explain.

Please check any of the following that apply to you

Any Other conditions we should know about?

Please carefully read the following information and accept the terms where indicated. For some specific symptoms and medical conditions, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.