Name *

First Name

Last Name

Phone

(###)

###

####

Are you pregnant or do you have any pregnancy-related conditions? *

Only if you've answered "No", you may proceed filling out the form.

Yes

No

Recovering from recent pregnancy

What modality are you interested in? *

Myofascial Release

Neuromuscular/Deep Tissue Massage

Sports/Stretch Facilitation

Swedish

Cupping

Gua Sha

Trigger Point Therapy

Sensory Repatterning

Do you have a preference for your massage therapist? *

Male

Female

No preference

Session Duration *

90 minutes

2 hours

Preferred Date? *

MM

DD

YYYY

Preferred Time? *

Hour

Minute

Second

AM PM

CONSENT & AGREEMENT *

I agree to receive massage therapy or stretching services and confirm that the health information I’ve provided is accurate to the best of my knowledge. I understand that my therapist will adjust techniques based on my comfort level and any conditions I disclose.

I understand that cancellations must be made at least 24 hours in advance to avoid being charged a cancellation fee.

How did you hear about us? *

Word of Mouth

Online Search

Referral