NEW CLIENT FORM - MASSAGE

First name

Last name

Phone

Birthday

Gender

Female

Male

Appointment Date & Time

Do you have any allergies or sensitivities to any plant/seed oils, lotions, essential oils, scents, etc?

Yes

If yes, please explain

Have you had any major operations within the last 6 months?

Yes

If yes, please explain

Are you currently suffering from any illness, infection, injuries, or do you bruise easily?

Yes

If yes, please explain

Are there any areas of the body that you would like focused on or avoided?

Yes

If yes, please explain

If you are pregnant, are you past your 1st trimester?

Yes

Not pregnant

By signing below, I am acknowledging that I have read, understood, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contra-actions and/or irritation to the skin/body from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I understand the above consent and will follow all aftercare instructions either given verbally or written.

I agree and consent to all of the above