Book an Appointment

First Name:

Last Name:

Phone:

E-Mail:

• Have you had a massage therapy before? yes No
• What is your stress leave 1-10 ...10 being the very worst? 1 2 3 4 5 6 7 8 9 10
• What pressure do you prefer? easy medium heavy
• Are you allergic to scents or oils? yes No
• Are you comfortable lying on your stomach? yes No
• Are you pregnant? No yes about how far along?  Not pregnant mounth (1) mounth (2) mounth (3) mounth (4) mounth (5) mounth (6) mounth (7) mounth (8) mounth (9)
• Are there any areas that cannot be addressed? yes No

Desired time for an appointment? 9:00 a.m. 9:30 a.m. 10:00 a.m. 10:30 a.m. 11:00 a.m. 11:30 a.m. 12:00 a.m. 12:30 a.m. 1:00 p.m. 1:30 p.m. 2:00 p.m. 2:30 p.m. 3:00 p.m. 3:30 p.m. 4:00 p.m. 4:30 p.m. 5:00 p.m. 5:30 p.m. 6:00 p.m. 6:30 p.m. Appointment reminder? yes No

Comments: If you have and question or concerns please list them so we can discuss them before your massage session.

:Type comments here.