Home
About
About Us
Testimonials
NeuroSpa Experience
Treatments
Massage Therapy
Therapeutic Massages
Pregnancy Massages
Spa & Healing Massages
Facials & Peels
HydraFacials
Image Facials
Peels
Microneedling
Dermaplaning
Spa Treatments
Eyelash Extensions
Brow & Eyelash Tinting
Manicures & Pedicures
Waxing
Men’s Spa Services
Body Treatments
Medical Laser
Laser Hair Removal
Laser Facial Rejuvenation
Skin Contouring & Resurfacing
Wellness
Weight Loss
Imagine Laserworks
Promotions
Spa Packages
Wedding Ready Packages
Membership
Blog
Contact
Massage Intake
Gift Cards
Shop Online
Search
Menu
Menu
Massage Intake Form
1
Contact Info
2
Massage Info
3
Medical History
4
Conditions
5
Consent
Contact Information
Name
*
First
Last
Email
*
Enter Email
Confirm Email
Primary Phone No.
*
Alternate Phone No.
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Date of Birth
*
DD slash MM slash YYYY
Emergency Contact
Name
Phone
Massage Safety Questions
The following information will be used to help plan safe and effective massage sessions. Please answer the questions to best of your knowledge.
1. Have you ever had a professional massage before?
*
Select...
No
Yes
2. Do you have any difficulty lying on your front, back or side?
*
Select...
No
Yes
2. Please explain
*
3. Do you have any allergies to oils, lotion, or ointments?
*
Select...
No
Yes
3. Please explain
*
4. Do you have sensitive skin?
*
Select...
No
Yes
4. Please explain
*
5. Are you wearing any of the following?
contact lenses
dentures
hearing aid
6. Do you sit for long hours at a workstation, computer or driving?
*
Select...
No
Yes
7. Do you perform any repetitive movement in your work or sports?
*
Select...
No
Yes
8. Do you experience stress in your work, family, or life?
*
Select...
No
Yes
8. How do you think it has affected your life?
*
Muscle tension
Anxiety
Insomnia
Irritability
Other
8. Other
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
*
Select...
No
Yes
9. Please identify
*
10. Do you have any particular goals in mind for this massage session?
*
Select...
No
Yes
10. Please explain
*
Medical History
In order to plan a massage session that is safe and effective, please provide some general information about your medical history.
Are you currently under medical supervision?
*
Select...
No
Yes
Please explain your situation
*
Do you see a chiropractor?
*
Select...
No
Yes
How often do you see your chiropractor?
*
Are you currently taking any medications?
*
Select...
No
Yes
Please list all medications
*
Medication
Dosage
Medical Contitions
Please check any condition listed below that applies to you.
Select Medical Conditions
contagious skin condition
easy bruising
epilepsy
recent surgery
diabetes
current fever
fibromyalgia
heart condition
tennis elbow
circulatory disorder
pregnancy
varicose veins
osteoporosis
recent fracture
cancer
decreased sensation
back/neck problems
allergies/sensitivity
carpel tunnel syndrome
atherosclerosis
joint disorder/rheumatoid arthritis
open sores or wounds
recent accident or injury
headaches/migraines
artificial joint
sprains/strains
swollen glands
TMJ
high or low blood pressure
Osteoarthritis/tendonitis
deep vein thrombosis/blood clots
Please explain any condition that you marked above with your massage practitioner prior to your session.
How many months pregnant are you?
*
Is there anything else about your health history that you think would be useful for your massage therapist to know?
Consent
Consent
*
I have read and agree to the terms below.
• I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.
• I understand that although massage can be therapeutic, it is not a substitute for medical examination, diagnosis, or treatment.
• I affirm that I have stated all my known medical conditions and answered all questions honestly.
• I agree to keep the therapist updated as to any changes in my medical profile.
We require 12 hours notice to cancel or reschedule an appointment. Failure to do so will require a $50.00 no-show fee.
Δ
Scroll to top