First Name

Last Name

Date of birth *

Age

Email address *

Phone number *

Emergency Contact *

Occupation

Street Address

City

Country

Postal code

Are you currently pregnant? *

Yes

No

How far along are you? (In case of Yes)

Do you have any high risk factors? (In case of Yes)

Do you suffer from chronic pain? *

Yes

No

Have you had a professional massage before?

Yes

No

What type of massage are you seeking? *

Relaxation

Therapeutic/Deep Tissue

Other

Other type of massage? *

What pressure do you prefer?

Light

Medium

Deep

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. *

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Signature date *

Medical Information

Massage Information