Massage Intake Form Massage Intake Form Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* How did you hear about us?Were you referred by someone? Please include their nameWhat is your occupation?Gender Identity Male Female Other HistoryAre you currently under medical supervision with a doctor? If yes, please explain:Do you see a chiropractor? If yes, how often?Are you currently taking any medication? Yes or No. If Yes, please listDo you have any nut, paraben, or gluten allergies?Massage ExperienceHave you had a professional massage before?YesNoWhat are your massage goals?Are there any specific areas of the body that you would like the therapist to focus on? (For example, left shoulder, neck, lower back.)If so, please list below:Please indicate below if you have or had any of these conditions below: Fibromyalgia contagious skin condition open sores or wounds easy bruising sprains/strains swollen glands allergies/sensitivity heart condition high or low blood pressure circulatory disorder varicose veins atherosclerosis phlebitis deep vein thrombosis/blood clots TMJ carpal tunnel syndrome pregnancy recent accident or injury recent fracture recent surgery artificial joint current fever joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis osteoporosis epilepsy headaches/migraines cancer diabetes decreased sensation back/neck problems Prenatal MassageIf you are pregnant, please be aware that *We do not offer massage in the first trimester of pregnancy.Hot Stone Massage is not recommended for guests with any of the following contraindications:blood clots or history of blood clots, easily bruises, currently have cancer and/or are receiving treatment for cancer, conditions that compromise the immune system diabetes, heart conditions, high or low blood pressure, skin inflammation or abrasions, pregnancy, blemishes, open wounds, varicose veins, neuropathy recovery from recent surgery. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. Consent to Treatment of Minor: IF UNDER THE AGE OF 18, PARENT’S/GUARDIAN NAME IS REQUIRED. The consent to treatment of minors must be signed by parent/guardian. CONSENT TO TREATMENT OF MINORS (Please use this portion for consent to provide massage therapy to those less than 18 years old) I (Parent/Guardian) hereby consent Release Well-Being Center to administer massage therapy techniques to my child of dependent as deemed necessary. By entering your name it serves as a signature and acknowledgement of the above.* First Last Today's Date Date Format: MM slash DD slash YYYY By submitting this form you confirm you have read and accepted the terms and conditionsPhoneThis field is for validation purposes and should be left unchanged.