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Is This a Couples Massage or Single?
Single
Couple
Personal Information
Room Number
*
Name
*
First
Last
Name (Second Guest)
*
First
Last
Email
*
Medical Information
Are There Any Allergies or Medical Information We Should Be Aware Of?
No
Yes
Please Detail Any Allergies or Medical Information We Should Be Aware Of
Are You Currently Pregnant?
No
Yes
How Far Along?
Are You Currently Under Care of a Physcian/Chiropractor?
No
Yes
Please Detail The Reason
Are There Any Current or Previous Injuries or Surgeries That We Should Be Aware Of?
No
Yes
Please Detail Any Current or Previous Injuries or Surgeries
Are There Any Current Areas Of Pain, Tension, or Discomfort (E.g. Arm, Leg, Neck, Etc.)
No
Yes
Please Detail Any Current Pain, Tension, or Discomfort Areas (E.g. arm, leg, neck, etc.)
Massage Information
Have Have You Had a Professional Massage Before?
Yes
No
Pressure or Information
What Type Of Massage Are You Seeking?
Relaxation
Therapeutic
What Type Of Massage Are You Seeking? (Second Guest)
Relaxation
Therapeutic
What Pressure Do You Prefer?
Light
Medium
Firm
What Pressure Do You Prefer? (Second Guest)
Light
Medium
Firm
Are There Any Areas (Feet, Face, Abdomen, etc.) You Do NOT Want Massaged?
Yes
No
Are There Any Areas (Feet, Face, Abdomen, etc.) You Do NOT Want Massaged? (Second Guest)
Yes
No
If yes, please indicate where?
If yes, please indicate where? (Second Guest)
Client Signature
*
Clear Signature
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