EmailMe Form - Original Flair Salon Massage Intake Form

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Phone

### - ### - ####

Do you currently have or have had in the past the following conditions in any form,
please check the appropriate box, please explain below.

Please explain any condition that you have marked above

Is there anything else about your health history that you think would be useful for your massage provider to know to plan a safe and effective massage session for you?

Any current tension/soreness in a specific area. If so, where?

Any numbness or stabbing pains anywhere. If so, where?

Are you taking any medications that I should know about?

Is this your first massage experience? If you no, when was your last massage?

Please explain your reason for having a massage

Please take a moment to read the following information:

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation. If I experience any pain or discomfort during this and future sessions, I will immediately inform the provider so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of.

Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and have answered all questions honestly.

I agree to keep the provider updated as to any changes in my medical profile and understand that there shall be no liability on the provider’s part should I fail to do so.

I also understand that if I cancel or do not show to my massage appointment without at least 24 hours in advance notice a $35 cancellation fee will be added to my profile and will be due prior to any future appointments setup.

Type your initials in the box below followed with your signature to complete form.

Signature

Clear

Date Time

MM / DD / YYYY