Massage Intake Form - ASP-MEDIEN.DE

We are required to have this information before we can provide any massage services. Please fill out this form as best as you can.

Contact Info

Name *

Address: *

Email: *

Phone *

Emergency Contact *

Contact's Phone: *

How did you hear about us? *

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Medical Information:

Are you taking any medications? *YesNo

If Yes, Please Describe *

Are you Pregnant? *YesNo

If Yes, Please Describe, (how far along, issues etc..) *

Have you had any recent surgeries? *YesNo

If yes, please Explain *

Do you suffer from chronic pain? *YesNo

If Yes, Please Describe *

Please explain any Conditions you have checked: *

Have you ever had a professional massage before? *YesNo

What pressure do you prefer? *LightMediumDeep

Do you have any allergies or sensitivities? *YesNo

If Yes, Please Explain *

Are there any areas you DO NOT want massaged? (face, feet, abdomen...)

What are your goals for this session? *

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Client Certification and Consent

Please Read:

By signing this form, you give express consent for Palm Tree Day Spa and its associates to perform massage therapy on you today. You also agree that with each visit, you will keep our associates updated on any changes to your health. You also agree that if there are any issues that were marked yes above, you hold Palm Tree Day Spa and its associates harmless in any issues that may arise from the services you received here with us today. This form, although filled out one time, is carried through your entire relationship with our company.

View Terms & Conditions:

Certify *I confirm I am the individual listed and agree with all Terms & Conditions

Pricing Notice: *While in service, your massage therapist may ask if you’d like to enhance your massage experience by adding CBD oil to your service, if you elect yes, an additional $20 will be added at checkout.
If you are scheduled for a Swedish massage and while in service you ask for a deep tissue massage, $10 will be added at checkout.Check to confirm you have read notice.

Client Signature *

Date Signed *

Save Info & Finish Later