Massage Intake Form for Dallas Relaxing Massage · Client Intake Form

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INTAKE FORM

Completing the intake form below will help to save time when your therapist arrives.

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MASSAGE INTAKE FORM - Coppell

Thank you for choosing Dallas Relaxing Massage for your next massage or spa event. To expedite your massage and minimize your wait time once our therapists arrive, please take a couple of minutes to compete the Client/Massage Intake Form below.

* denotes a required field

Your Contact Information
* Name
* Email Address
* Your Address
* City
* State
* Zip
* Best Phone#
Alternate Phone#

Date of Birth

Month

Day

Year

Emergency Contact:
Emergency Phone#:

Your Massage Preferences
Your Occupation:
Primary reason for Massage:: i.e. manage pain, relieve discomfort, maintain health, reduce stress, simply relax, etc.

Have you ever had a professional massage before?

(please indicate)

Yes

Would you like us to avoid any specific area(s) for health reasons, or any areas you simply do not wish or like to have massaged?

(please indicate)

What type of massage pressure do you typically enjoy?

(please indicate)

Light

Medium

Firm

Deep Tissue

Your Health Information (please check all that apply)

Allergies	Fainting Spells	Numbness/Tingling
Arteriosclerosis	Headaches	Pacemaker
Arthritis/Bursitis	Heart Trouble	Pregnant
Back/Neck Injury	Herniated Disc	Recent Surgery
Blood Clots	Hypertension	Skin Disorder
Cancer	Infectious Disease	Spinal Injury
Diabetes	Low Blood Pressure	Stroke
Epileptic/Seizures	Nausea	Varicose Veins

CLIENT AGREEMENT

I understand that massage therapy involves neither diagnosis nor treatment of illnesses or injuries and it is not a substitute for medical care. I am solely responsible for my physical condition and for seeking medical treatment when I feel it is necessary for my well-being.

I am aware that failure to alert my therapist to any of these conditions could result in adverse effects. I hereby voluntarily assume all such risks of loss, damage, or injury that my may be sustained. In consideration of participating, I hereby waive any and all claims of personal injury I might now or in the future have against Dallas Relaxing Massage or any of their affiliates, including but not limited to the following: (1) Illness; (2) Injury; or (3) Disablement, however caused, related directly or indirectly to my participation. This release shall be binding upon the undersigned, his/her heirs, next of kin, and personal representatives.

Types of massage techniques the therapist anticipates using during the session include, but are not limited to: acupressure massage, carpal tunnel massage, craniosacral therapy, deep tissue massage, facelift massage, hot stone massage, lomi lomi massage, lymphatic drainage, myofascial release, pregnancy/prenatal massage, reflexology, Reiki, sports massage, Swedish massage, Thai massage, TMJ and trigger point massage.

Body parts to be massaged include the face, neck, shoulders, back, arms, buttocks, hip flexors,legs (front and back), pectorals, abdominals, ribs, and feet.

The massage therapist will not engage in breast massage unless requested by the client.

Standard draping will be used, unless otherwise agreed to by therapist and client.

Digital Signature

I have completely read and thoroughly understand the "CLIENT AGREEMENT" above. I understand that inputting my name below is the equivalent to my legal signature.

(* required)

Send Your Massage Intake Form