Massage Health Profile
Please fill out prior to your massage appointment.
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Email *
Client Name *
Date of Birth *
Phone Number *
Email *
Occupation? *
Emergency Contact Name & Number *
Check All That Apply: *
Required
Do you have any allergies and/or skin sensitivities? *
Please list any medications you are taking? *
Please describe any accidents, surgeries, or injuries? *
Activity Level?  *
Is this your first massage experience?  *
What are you looking for from this massage? *
Required
Do you prefer a male or female therapist? *
On A Scale Of 1-10 What is your Pressure Preference?  *
Light
Deep Tissue
Are you comfortable with your massage therapist working on the following areas?  *
Required
I understand that:
 
- I must contact Pure Massage within 24 hours of my scheduled reservation if I need to cancel or reschedule my massage for any reason.
 
-If I fail to attend my scheduled massage, make any changes, or cancel with less than 24 hours I will be charged a cancellation fee of the cost of the service.
 
-Monthly massages are valid for 30 days, do not roll over, and are non-transferrable
 
-If I hold/stop my membership I must contact Pure Massage directly to remove/adjust any future reservations

-If I am late, my session will end at the original scheduled time so that the client following me is not penalized.  


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 the session, I will immediately inform the practitioner so the pressure and/or techniques may be adjusted to my level of comfort.  I also understand that massage is not intended to diagnose or treat any medical condition and that nothing said or done during the massage should be construed as such.  Because massage should not be performed under certain circumstances, I attest to keep my practitioner up to date on any changes in my medical conditions and understand that there shall be no liability on the part of the practitioner should I fail to do so.  I also understand that any illicit remarks/actions of a sexual nature will result in an immediate termination of my massage session and I will be responsible for full payment of service.

I hereby certify that I have read and agree to all of the above provisions. (Enter name & date in box below)
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