Client Intake Form - All Bottled Up Massage

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First Name(Required)

Last Name(Required)

Phone Number(Required)

Birth Date(Required)

MM slash DD slash YYYY

Email(Required)

How did you hear of AllBottledUp Massage?

How often do you get a massage?

Every two weeks

Once a month

Once every 3-6 month

Once a year

Do you have any contraindications or problem areas, I should know about? What areas would you like more focus on?

What kind of pressure do you prefer?

What are your areas of discomfort/pain?

What are the onset of discomfort/pain?

rate of discomfort

1 - Little Painful	2	3	4	5 - Very Painful

Frequency of pain

At what time of day is the pain at its worse?

Is there anything you do that creates, increases or decreases pain?

What are the physical duties required of your occupation?

Would you like to add an upgrade to your massage today?

Hot Stone $15

Helps relieve muscle tension and pain. Heat has long been used to ease muscle tension and pain. Reduces stress and anxiety. Promotes sleep. May help relieve symptoms of autoimmune diseases.

Facial Light therapy $15

A non-invasive treatment that enters the skin’s layers to improve the skin and reduce inflammation and stimulate the production of collagen. Leaving face rejuvenated and firm. Helps with mood and anxiety.

Thai Stretch therapy $15

Increases your flexibility and range of motion by improving your muscle’s blood flow and oxygen supply. Eases back pain. Reduces headache pain. Lower stress and anxiety. Aids in digestion.

Sarga Body Work $15

Barefoot message using aerial fabric strap and gravitational strength to stretch and lengthen the fascia which surrounds the muscle of your body. It can help to treat muscle pain, inflammation and restriction by relaxing contracted muscles, stimulating length and hydration in the tissue, and improving blood and lymphatic circulation.

Client Agreement

— Client information are confidential and written authorization is required to release any information.

— We do not double book appointments.

— Please reschedule session if more than 15 minutes late.

— 24 hour cancellation notice is required. Cancellation fee of full amount will be applied to all cancellations made less than 24hrs notice.

— You will be draped and at no time be exposed.

— You will have a consultation with your therapist to discuss the session.

— You may end the session at any time for any reason and/or therapist can end session.

— Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law.

I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction. I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

By my electronic signature below, I agree to the massage policy and client agreement above.

Signature(Required)

~ Client Intake ~

Are you ready to make yourself a priority?

Get in touch today for a custom wellness plan