New Client Intake

Thanks for scheduling your first appointment at THE SPACE!

We look forward to meeting you.

Please take the time to fill out this form prior to your appointment.


IMPORTANT! I know you want to rush through this, but the more detail you give, especially in the comments, the more I can cater a massage to you and your needs. I can't tell you how many intake forms I receive that are nearly empty, just to have a client come in and then remember the ankle pain they've had for weeks, that auto accident 6 months ago or last years surgery. It ALL matters. So please, take a minute to fill this out and leave some comments, even if you want just a relaxation massage.

 
Name *
Name
Date of Birth
Date of Birth
Address
Address
Emergency Contact
Emergency Contact
Emergency Contact
Emergency Contact
Section
Health Quesionaire
Please take a minute to read through and answer any questions honestly. Specific medical conditions can be contraindicated for Ashiatsu massage and a referral from your primary care provider may be required. Please check all that apply
Thanks for taking the time to fill out this form prior to your appointmet I look forward to seeing you at your schdeudled day and time. Remember that time is reserved for you. Please arrive on time as I am not able to go over on appointment time.