NameDate of BirthEmergency Contact NamePhoneHave you had a professional massage before?yesnoAre you pregnant?yesnoList any allergies (especially anything that could be in lotions, oils, creams):Reason for initial visit:I agree that all of the information I have provided is correct:YesI understand that massage is not a replacement for medical care and no medical diagnosis will be made. Because massage and bodywork may be a contraindication due to certain medical conditions, I affirm that I have informed the therapist of all known medical conditions and will keep the therapist updated as to any changes in my medical condition going forward. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/ or manipulations, draping, or environment may be adjusted to my comfort level. Any illicit or sexually suggestive comments or actions made by me will result in immediate termination of the session and I am responsible for the full payment. I have read and agree to the terms above:YesRegister