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Please tell me a little about your massage request.
These simple questions will allow me to prepare your customized session, and minimize any risks. Please fill out as much as possible if you can. Thank you.
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No appointments will be scheduled unless we have a working contact number and physical address of the session to include gate codes for access, room numbers for hotels (unless it is not known at the time of booking but must be submitted within 24 hours of your agreed time.
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I have read and understand the above statements
First Name & Last Initial Only
*
Your answer
What is the best way to contact you?
*
Text/SMS
Email
Call
Required
Please add the best number to call or text you below for an easy and quick response.
*
Your answer
Your Gender
Female
Male
Prefer not to say
Other:
Clear selection
What is your age range?
18-29
30-49
50+
Prefer not to say
Clear selection
How many minutes of a session are you looking for?
60
90
120
Clear selection
What kind of work do you do?
Sit at desk
Heavy Lifting
On my feet a lot
Siting most the time
Other:
What is your level of activity?
Sedentary
Exercise sometimes
Exercise 2-3 week
Exercise 3+ week
Other:
Clear selection
Please choose as many or as few of the following reasons for your massage.
Pure Relaxation
Stress Relief
Prenatal
Therapeutic Touch
Sore area
Medical Massage
Reenergize
Immobility
Lower back/Upper Back tension
CBD Infusion Upgrade ($20)
Other:
Please elaborate on anything specific from above
Your answer
What is your current discomfort level, if any?
None
1
2
3
4
5
6
7
8
9
10
So bad it affects activities and sleep
Clear selection
Would you like any add-ons to your customized session? (All included with 120-minute massages if required)
Rapid Tension Relief (Hypervolt) included with 90 minute +
Proprioceptive Neuromuscular Facilitation (Contract/Release Stretching) +$30 for 30 minute session
Hot Stone included with 120 minute session, or $15 for 90 minute session or less.
Trigger Point Therapy included with 90 minute or more session
Myofascial release included with 90 minute or more session
Aromatherapy included upon request all sessions
Cupping (Myofasical decompression)
Other:
What payment method will you be using to pay?
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Cash
CashApp
Venmo
Credit Card (Will be accepting soon)
Required
How did you hear about my services?
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Thervo
Thumbtack
Massage Finder
Referral
Facebook
Nextdoor App
The Powerful Body Website
Chair Massage Event
Other:
Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I may have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals, and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis I must provide a physician’s written consent prior to services.
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I have read and understand the above statements
If the client is uncomfortable for any reason, the client may ask to end the massage session, and the session will be ended.
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I have read and understand the above statements
Draping will be used during the massage session as per TDLR requirements.
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I have read and understand the above statements
I understand that close contact with people increases the risk of infection from COVID-19. By checking "I concur...", on this form, I acknowledge that I am aware of the risks involved and give consent to receive a massage from this practitioner.”
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I concur, and am aware of the risks
I do not concur, and have chosen to not have a massage today
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