New Client Massage Form

Name *

Email address *

Phone number *

Date *

Appointment for a minor under the age of 18? *

No

Yes

Are you taking any medications that would pertain to massage? *

Please select at least one option.

Blood Pressure Medication

Daily Aspirin

Pain Medication

Sleep Aids

Muscle Relaxers

No

Are you currently pregnant? *

No

Yes

Have you had any injuries? *

Where do you carry your tension and/or pain? *

Please indicate any of the following medical concerns that apply to you: *

Please select at least one option.

Cancer

Headaches/Migraines

Arthritis

Diabetes

Neuropathy

Joint Replacement

High/Low Blood Pressure

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Open Wounds

Muscle Ruptures

Tendon Ruptures

Partial Muscle and Tendon Tears

Contusions (Bruises)

Burns

Broken Bones

Joint Replacements

Sprains and Strains

Gout

Bursitis

Infections of the Skin and Soft Tissue

Aneurysms

Varicose Veins

Artificial Blood Vessels

Bleeding Disorders

Tumors

I'm unaware of any medical conditions.

Please explain any of the above conditions that apply. I (the client) understand that if I choose not to disclose this information to the service providers that I cannot hold Awaken-Zen Spa responsible in any legal capacity if an issue arises. *

Do you have any allergies or sensitivities? *

Do you have an implanted birth control device in your arm? *

No/Does not apply

Yes, Left Arm

Yes, Right Arm

What type of service are you seeking? *

Therapeutic + Relaxation Combo

Therapeutic

Relaxation

What type of pressure do you prefer? *

Light

Medium

Deep

Select your primary area of concern/pain: *

Shoulders & Upper Back

Middle & Lower Back

Neck & Head

Hands & Arms

Feet & Legs

Hips

Select a secondary area of concern/pain if applicable: *

Shoulders & Upper Back

Middle & Lower Back

Neck & Head

Hands & Arms

Feet & Legs

Hips

N/A

How do you want your time divided?

Balanced Focus (Standard Full Body): Time is evenly distributed for a full-body treatment.

Targeted Full Body: Full-body treatment with extra attention given to specific area/s of concern.

Problem Area Focus: Concentrated treatment on specific problem areas, skipping other regions as needed.

Are there any areas you do not want massage? *

Please select at least one option.

I understand that I can disrobe to my comfort level, but clothed areas may require different massage techniques. *

Massage to the side of the hip can be done directly with proper draping, or through the sheet if preferred. If you do not want hip/glute massage, please indicate above.

Are you open to stretches being included in the massage? *

Yes

No

Medium Application Style *

No Medium: Ideal for treatments like Lymphatic Massage, Deep Tissue Sculpting, Shiatsu, Tui Na, and Blissful Slumber.

Light Application: Minimal use of massage medium.

Standard Application: Balanced use of medium for optimal glide.

Generous Application: Extra medium for a more luxurious experience.

Massage Medium (Base) *

Essential Oils *

Additional Medium Options

Do you have a specific goal or any special requests for the massage?

Please select at least one option.

I understand that by acknowledging here, I (the client) have provided all information requested and withhold Awaken-Zen Spa from all legal liability if information was not disclosed. *

Please select at least one option.

I authorize and request massage treatments from Awaken-Zen Spa. *

Please select at least one option.

I have reviewed the HIPAA disclosure in the URL below. I understand my rights and consent to how my personal information will be handled and disclosed in accordance with the HIPAA guidelines. URL: www.awakenzenspa.com *

Please select at least one option.

"I acknowledge that Awaken-Zen Spa requires a $25 prepayment to book my appointment. To receive a refund, I must cancel at least 24 hours before the appointment." *

Please select at least one option.

"I understand the therapist will call my listed phone number. If I don't answer or arrive at Awaken-Zen Spa within 20 minutes of the scheduled time, the appointment will be marked as a no-show, and the $25 prepayment will be kept as a no-show fee, non-refundable." *

Please select at least one option.

I agree to pay Awaken-Zen Spa for services rendered, and if paying by card, I authorize Awaken-Zen Spa to process my payment with the card I provided. *

Please select at least one option.

I understand that therapeutic massage is not a substitute for traditional medical treatment or medications. *

Please select at least one option.

I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications. *

Please select at least one option.

I have clearance from my physician to receive massage therapy. *

Please select at least one option.

I understand that massage therapy carries certain risks, which may include superficial bruising, short-term muscle soreness, and the worsening of unknown injuries. I acknowledge these risks and release both the company and the individual massage therapist from any liability for injuries that may occur during the massage session. *

Please select at least one option.

I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition. *

Please select at least one option.

I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly. *

Please select at least one option.

I understand that I or the massage therapist may terminate the session at any time. *

Please select at least one option.

I understand that the massage therapy procedures and techniques used at Awaken-Zen Spa by the provider listed above are for therapeutic relief and stress management. At no time will I solicit any sexual suggestions or requests. I further understand that the massage provider will not tolerate any such solicitation. If this occurs, the massage provider will end the treatment session and I will be responsible for payment of the full treatment. *

Please select at least one option.

I have been given a chance to ask questions about the massage therapy session and my questions have been answered. Please call or text (602) 688-2578 with any questions if necessary.

Awaken Zen Spa