Massage Intake Form
For the following services:

Massage

Hopi Ear Candling & Head Massage

Chakra Healing Therapy

Are you Pregnant?
Medical Information
Are you taking any medications?
Do you suffer from chronic pain?
Please indicate any of the fllowng. that apply to you:
Massage Information
Have you had a professional massage before?
What type of massage are you seeking?
What pressure do you prefer?
Do you have any allergies/sensitivities?

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