Massage Intake Form FacebookThis field is for validation purposes and should be left unchanged.ContactName(Required) First Last Email(Required) Phone(Required)Phone Type(Required) Home Mobile Work Other It's OK to text me! Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required)OccupationEmergency Contact(Required)Emergency Contact Phone(Required)Emergency Contact RelationshipHistoryHow did you hear about us? Internet Search Email Drive By/Signs LaVida Massage Employee Gift Cards TV/Radio Print Ad/Magazine LaVida Massage Client Other How often do you receive professional massages? First Time Once a year or less 2-3 times/year 4-6 times/yr 7-10 times/yr Monthly or more frequent What prevents you from receiving massage for frequently? Cost Time Other Are you here today for: Relaxation Stress Relief Soreness General Health & Wellness Headaches Injury Rehab How often you would like to get a massage? First Time Once a year or less 2-3 times/year 4-6 times/yr 7-10 times/yr Monthly or more frequent Name of ReferrerOther DescriptionOther DescriptionMedical ConditionsCheck all that apply(Required) Warts Seizures Varicose Veins Numbness/Tingling Birth Control Implant Arthritis Athletes Foot Blood Clots Blood Pressure Bruise Easily Cancer (active) Diabetes Fibromyalgia Headaches Jaw Pain/TMJ Leg or Knee Pain Neck or Back None Please list any medications you are taking(Required)Please list any other medical conditions(Required)Are you pregnant?(Required) No Yes If yes, how many weeks?If yes, are you experiencing any of the following? Cramping/Soreness Morning Sickness Pre-Eclampsia Swelling (Edema) Due DateDo you have any allergies or skin sensitivities?(Required) No Yes If yes, please list:Our lotion products may contain nut oils. Are you allergic to nuts?(Required) No Yes If yes, which nuts?What areas would you like us to focus on today?(Required) Right leg Left leg Right arm Left arm Neck Shoulders Back Head Right foot Left foot Glutes None What areas would you like to avoid?(Required) Right leg Left leg Right arm Left arm Neck Shoulders Back Head Right foot Left foot Glutes None Tell us about your current pain level. Check the number below:(Required)0 - Pain Free12345678910 - Extreme PainTell us about your current stress level. Check the number below:(Required)0 - Completely Relaxed12345678910 - Very StressedConsent(Required) I agree to the notice.IMPORTANT NOTICE: If you have certain medical conditions or symptoms, receiving a massage may aggravate or worsen that condition. If you are experiencing a cold, fl u, fever, or have consumed alcohol in the past 12 hours, your session must be rescheduled for 48 hours after symptoms disappear. By signing below, I am stating that I understand there are benefi ts and risks of massage therapy. I understand that massage is not a replacement for medical care, or medical examination. I acknowledge that any recommendation made by my massage therapist is not considered a medical diagnosis, or advice and that there is no stated promise of success of techniques, or services. I have listed all medical conditions (including past conditions, such as operations) that I am aware of and this information is true and accurate to the best of my knowledge. Before beginning a future session, I agree to inform the massage therapist immediately of any change in my health. I acknowledge that this information is confi dential and intended for review by massage therapists, that a medical referral may be requested of me, and that LaVida Massage is not liable for the management of any condition whether it is identified or not on this form. This center location is independently owned. I agree to inform my massage therapist of any discomfort or pain experienced during the session so any adjustments can be made to the pressure, draping or environment. LaVida Massage is not liable for any injury or condition that arises from the application of massage, despite the completion of this form. This form is only intended as an assessment tool and serves as a guide for the application of massage. All services include 5 minutes for pre-consultation and un-dressing and 5 minutes for post-consultation and re-dressing. I also understand that any illicit or sexually suggestive remarks or advances, made by myself, will result in immediate termination of the session, and that I will be liable for full payment of the session.Signature(Required)
