Massage Consent Form

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First & Last Name

Email

Code

Phone

Date of Birth

Occupation

Emergency Contact (Name & Phone Number

Have you had professional massage before? *

Yes

No

Do you have any of the following? * Required

High or low blood pressure

Cancer

Headaches/migraines

Stroke

Arthritis

Heart attacks

Blood clots

Chronic pain

Joint replacement

Sprains or strains

Broken bones within the last year

Eczema

Varicose veins

Back/neck problems

Diabetes

Other (Please Specify Below)

None

Please specify above here

Do you have any particular areas of discomfort?

I would like to receive a reminder 24 hours before the appointment.

I agree to the Movement Studio Policy Notification?View Policy Notification

I agree and understand there is a 12 hour cancelation policy and if I cancel within this timeframe I will be charged 100% of the appointment fee.

Please sign below by typing full name and date

Thanks for submitting!

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