Bambi's Bliss Request Form

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Thank you for visiting! Please fill this form out and text the word "BLISS" when completed to receive your Customized Therapeutic Massage Intake Form.

Email *

First and Last Name *

Phone Number *

How did you hear about Bambi's Bliss? *

Google Search

Yelp

Social Media (Facebook, Instagram, Snapchat, Twitter)

Better Business Bureau

Referral (please list name below)

Voucher or Discount code (please list voucher number or code in "OTHER" section)

Other:

Required

Requested Service Address *

Stutz Business Center- 1060 N. Capitol Ave Indianapolis, IN 46204

My address (please type address in "OTHER" section)

My chair massage event-2 hr minimum (please type address in "OTHER" section)

Other:

Required

Requested Service Date and Time *

YYYY

Time

Requested Massage Type *

Utopia Table (Table and Headphones only)

Nap & Nirvana (Type A Massage and 15+ min Meditation)

Type A- I want to Relax, BNS, Star, or Me & Baby (Swedish, Target areas, or Prenatal)

Type B- More Pressure Please, Get These Knots Out, or Stretch Out the Stress (Deep Tissue, Trigger Point, or Sports)

Type C- Abhyanga (Ayurvedic)

Type C- Cloud 9 Cupping (Deep Tissue and Cupping)

Type C- Bambi's Bamboo (Bamboo)

Type C- Bliss Bubbly, & Burgers (Massage, Meal & Drink)

Back to Back Bliss (Consecutive Couples)

Mobile Massage at my Location (Traditional massage table, NO Utopia Table)

Mobile Chair Massage Event (Chair Massage, 2 hr minimum)

Other:

Required

Requested Session Length *

30 mins

45 mins

60 mins

75 mins (1 hr 15 mins)

90 mins (1 hr 30 mins)

120 mins (2 hr)

135 mins (2 hr 15 mins)

150 mins (2 hr 30 mins)

180 mins (3 hr)

210 mins (3 hr 30 mins)

240 mins (4 hr)

Other:

Required

Would you like any add-ons? *

Arnica Gel, Biofreeze, or Peppermint Scalp Massage ($5)

CBD Salve ($10)

Back Scrub or Foot Scrub ($5 or $10)

Cupping ($15)

Bamboo ($15)

Hot Stones ($15)

Bliss, Bubbly & Burgers ($15)

Headlight Restoration ($30)

I'd like an appointment scheduled after regular business hours(after 5:30 pm Mon-Fri, after 2 pm Sat, any time Sun)($15)

No, thank you

Required

Reason for your visit (Please write what's bothering you in the Other Section) *

Muscle Pain

Stress

Injury

Self-Care

Other:

Required

Utopia Table FAQs

Please read and check each box for your massage inquiry *

I understand this is a massage REQUEST not a confirmation. Once confirmed I will place a credit card on file to hold my appointment.

I have watched the Utopia Table FAQs video and understand how the Utopia Table may affect me. I understand the health contraindications and weight restrictions of all massage equipment and will be liable for any damages. I understand I am not to touch any of the electrical equipment under the Utopia Table.

Discounts, vouchers or referral codes may not be combined. One per first time client only. Any discounts, vouchers, or referral codes should be acknowledged by the therapist prior to treatment.

I understand there may be additional add-on fees or after business hour fees. I agree to pay the $30 cancellation invoice if I have not given notice within 12 hours.

I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I affirm that I have notified my therapist of all known medical conditions, allergies and injuries. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand I must provide adequate area of at least 8x5 feet space for the therapist to perform chair or table services for all mobile services.

I understand Bambi's Bliss is an affiliate of the Better Business Bureau and I will be properly covered according to Indiana draping laws. I understand that massage is entirely therapeutic and non-sexual in nature and I am not to touch the therapist at any time.I understand if any sexual remarks or acts are made by me I agree to pay for the service in full along with any additional fees and/or litigation.

I understand that I am responsible for all parking fees if I have not texted the therapist the parking space number upon arriving.

I understand I must text "BLISS" after completing this request form. I will then receive my payment confirmation.

Required

Comments or questions

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