Massage Form

Name:*
Email:*
Phone*
Address*
Emergency Contact & Phone #
Who Should We Thank For This Referral?
Have You Had A Massage Before?
- Yes
- No
Do You See A Chiropractor?
- Yes
- No
How Often Do You Exercise A Week?
List All Allergies
Please Let Us Know If You Are…
- Pregnant
- Have High Blood Pressure
- Have A Heart Condition
Do You Have Any Bone/Structural Issues?
- Yes
- No
List All Surgeries Within The Past 4 Years
Please Read And Check The Following:*
- I Understand That This Massage Is Not A Replacement For Medical Care And That No Diagnosis Will Be Made
Please Read And Check The Following:*
- I Am Responsible For Paying A $50 Fee For Any Appointment Cancellation Of Less Then 24 Hours
Name:
Birthday

AG Massage & Bodywork LLC