Client Intake and Preferences
Eileen Monaghan, LMT | 757.553.4052 | 3630 South Plaza Trail, Suite 110 Virginia Beach, VA 23452 www.monaghan-massage.com | www.hrprenatalmassage.com

Please complete this brief Client Intake & Preferences form to the best of your knowledge before your first appointment.  The following information will be used to help plan safe and effective massage sessions. It will be kept confidential, unless a separate Release Form is signed.

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Email address *
Full Name (First and Last) *
Street address *
City *
State *
Zip Code *
Phone number *
Date of Birth *
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Please send me electronic confirmations for appointments via: *
Please send me e-newsletters and special announcements via:
선택해제
Emergency Contact (Full name) *
Relationship to emergency contact *
Phone numer of emergency contact *
Have you received a professional massage before? *
If you answered yes to receiving a professional massage before, when was the last time you had a massage?
How much water do you drink daily? *
Please list areas of tension, stress or pain you wish to be addressed
Please list any current medications (over the counter or prescribed), Vitamins and/or Herbs.
Please list any past or present surgeries/injuries/illnesses
Please list any known allergies (skin or internal) to oils, plants, flowers, seeds, and/or nuts.
Please check off any of the following that apply to you.
If you check any of the above conditions, please add any extra information here:
Do you exercise? *
If you answered yes to the exercise question, please list what kind and frequency
How did you hear about me? *
Being that massage should not be done or doctor's permission may be needed under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully and to the best of my knowledge.  I understand that the Massage/Reflexology/Cupping I receive is for the purpose of stress reduction and the and the relief from muscular tension.  If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure and/or methods can be adjusted.  I understand that my Massage Therapist does not diagnose illnesses/disease nor perform any spinal manipulations and does not prescribe any medications/treatments.  I acknowledge that massage is not a substitute for a medical examination and that I should see my health care provider for those services. Sexual advances and other verbal or physical conduct of a sexual nature will not be tolerated. *
Cancellation Policy: I understand that there are times when you must miss an appointment due to emergencies or obligations to work or family. However, when you do not call to cancel an appointment you may be preventing another client from receiving a much-needed massage. Conversely, the situation may arise where another client fails to cancel an appointment and I am unable to schedule you for a massage due to a seemingly “full” appointment book.If an appointment is not cancelled at least 12 hours in advance, you will be charged 50% of the session price.If you do not show up to your appointment and you give no notice (No Show), you will be charged the full amount of the session missed. This policy will be held for ALL clients. You must pay for your missed appointment prior to your next appointment.You must contact me via text/call to schedule your next appointment after a missed appointment. Online scheduling will not be made available to you until you have paid all fees. Clients that habitually cancel without notice may be asked to pay for appointments prior to session or may be asked to use another Massage Therapist from then on. *
Scheduled Appointments:  I understand that delays can happen. Please allow ample time to get to your appointment on time. My appointments run back to back, with enough time for me to take payment and set up my room for my next appointment. If I am running late for any reason, I will give you your full time. If you are running late, you will receive whatever time is left so I can keep all my other sessions from running late. Thank you for your continued support of me! If you have any further questions, please don’t hesitate in contacting me. *
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