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Majestic Spa & Salon Massage Intake Form
Confidential Information
Welcome! We want to make your appointment as pleasant and comfortable as possible. If at any time you have any questions regarding your visit, please let us know.
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Email
*
Your email
Name (Please Print)
*
Your answer
Phone Number
*
Your answer
Referred By
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Your answer
Zip Code
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Have you ever received massage therapy?
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YES
NO
Do you have any of the following today?
*
Sunburn
Inflammation
Severe Pain
Headache/Migraine
Cuts, Bruises, or Burns
Irritated Skin Rash
Poison Ivy/Oak
Cold/Flu
None
Required
How many times a week do you participate in exercise and/or sports?
Your answer
Are there any specific areas you would like worked on today?
Your answer
Are there any other health conditions we should be aware of?
If yes, please be specific
*
Your answer
I understand that this massage is not a replacement for medical care and that no diagnosis will be made
Please Initial
*
Your answer
I am responsible for paying for any appointment cancellation of less than 24 hours
Please Initial
*
Your answer
The treatments I receive here are voluntary and I release Majestic Spa and Salon from liability and assume full responsibility
Please Give Name and Date
*
Your answer
Send me a copy of my responses.
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