Massage Client Consultation Form:
Thank you for the opportunity to support you in revealing your happiest, healthiest, self! Please fill out this brief consultation form.
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Name/Relation
How did you hear about us?
Have you ever had a massage before?
Are you sensitive to touch in any specific area?
Do you have tension or soreness in a specific area?
Are there any areas that you would like me to avoid?
What is your preferred level of pressure?
Any Allergies? (Check all that apply)
Shell fish (glucosamine)
Any other allergies we need to know about? What type of reaction does it cause?
Any prescription drugs, supplements or herbal remedies that could affect your skin?
No prescription drugs
I am taking Accutane
I am taking Antibiotics
I am taking blood thinners (anticoagulants)
I am taking medication that increases light sensitivity or phytotoxicity
Please check any that apply?
None of the below
Any cardiac or circulatory problems?
Do you have high blood pressure?
Do you have arthritis?
Do you have frequent headaches?
Do you have epilepsy or seizures?
Do you have any type of infection of the urinary system?
Do you have Crohn's disease?
Do you have Hyperthyroidism?
Do you have Lymphedema?
Do you have Deep Tissue Thrombosis?
Are you pregnant or nursing?
If pregnant how far along?
Any other medical conditions or previous medical conditions that could affect your skin or to be touched in a specific area (such as surgery, cancer, autoimmune disorders, etc)?
Have you had a medical cosmetic treatment or surgery within the past year?
No medical cosmetic treatments within the past year
I have had facial injections within the past 2 weeks (ex: botulinum toxin A such as Botox, Xeomin, or fillers such as Juvederm and Restylane).
I have had facial cosmetic surgery within the past year (face lift, neck lift, rhinoplasty, etc).
I have had a laser or IPL (Intense Pulsed Light) treatment, or a medical grade chemical peel within the past year.
I have had surgery in the past year.
Anything else you'd like to share about yourself?
The body can store emotions in the muscles and vital energy points. The trapped energy can cause emotional and physical discomfort. Could there be an emotional component holding you back? Sometimes there may be an emotional piece causing muscle and nervous system tension.
PHOTO RELEASE: I give permission to Birch Botanical Spa to use and publish my photograph for educational and promotional purposes without compensation.
Your health and wellness is our goal! With that in mind, please note the following: If my purpose for receiving treatments is to improve my health, I agree to follow both any home care and massage treatment schedule outlined for me by my Birch Botanical Spa practitioner. I acknowledge that Birch Botanical Spa services are not substitute for medical care, medical exams, or diagnosis. If I experience an unexpected reaction to a treatment, service or to a recommended product, or have any questions about my prescribed home care regimen, I will contact Birch Botanical Spa expediently for guidance. I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Birch Botanical Spa and/or the professional from liability and assume full responsibility thereof.
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