Patient Info Name(Required) Birth Date(Required) MM slash DD slash YYYY Address(Required) Cell(Required)Email(Required) Where did you hear about Traditional Thai Massage & Wellness?(Required) Google Maps Yelp Angie’s List Website Facebook Other What do you hope to receive from this session?(Required) Please check if you have any of the following conditions(Required) Open wounds Bruise easily Pregnant Back Pain Sensitive to pressure Neck and Shoulder Broken bones in past year Any injuries in the past year Numbness of stabbing pains Any surgery recently How often you get a massage:(Required) 1 a week 1 a month Every other month Allergies / Sensitivity to lotion or oil we need to be aware of?(Required) All information given is strictly confidential and will not be used for any purpose I ALSO UNDERSTAND THAT THIS IS STRICTLY PROFESSIONAL THERAPEUTIC MASSAGE. ANY INAPPROPRIATE TOUCHING OF THERAPIST OR BEHAVIOR, ANY ILLICIT OR SEXUALLY SUGGESTIVE REMARKS OR ADVANCES WILL NOT BE TOLERATED. THE RESULT OF SUCH WILL BE IMMEDIATE TERMINATION OF THE MASSAGE SESSION, WITH COMPLETE PAYMENT FOR APPOINTMENT MADE I agree to terms of this form(Required) Download Form as PDF
