Massage Intake Contact Information First Name Last Name Date Of Birth (Mm/Dd/Yyyy) * Street Address 1* City* State* Postal Code* Primary Email * Home Phone * Cell Phone * Cell Phone Carrier Please select oneAt&tTMobileSprintVerizone Emergency Contact and Medical Contact Emergency Contact Name * Emergency Phone Number * Primary Care Physician Name Physican Phone (If Unknown, Name City He Or She Is In) General And Medical Information Do You Suffer From Any Of The Below? Heart Condition* YesNo High Blood Pressure* YesNo Blood Clots* YesNo Varicose Veins* YesNo Cancer* YesNo Diabetes* YesNo Urinary Problems* YesNo Muscle/Joint Pain* YesNo Nerve Pain, Tingling, Loss Of Sensation* YesNo Arthritis* YesNo Respiratory Problem* YesNo Skin Problems* YesNo Headaches / Migraines* YesNo Herniated Or Bulding Discs In The Neck Or Back* YesNo Allergies* YesNo Fibromyalgia* YesNo General Information To Maximize Safety And Effectiveness Of Your Massage Treatment Have You Ever Had A Massage? If So What Type?* Are You Currently Pregnant? If So How Far Along?* Have You Previously Had Any Surgeries? If So List Where* Are You Currently Under The Care Of A Doctor? If So, List Name* Are You Allergic Or Sensitive To Any Oils (Nuts, Scents,Etc)?* Which Of The Area(S) Would You Like The Therapist To Focus On? * What Are Your Goals For Your Massage Therapy Treatment Program?* Do You Have Time To Perfrom Recommended Therapeutic Exercises?* YesNo Please follow our 24 hour cancellation policy. If you have to change your appointment please call us directly at 856-751-8881 within 24 hours of your appointment time or you will be charged the value of your scheduled massage.