Massage Intake

Please complete the form below prior to your appointment.

First Name

Referred by

Last Name

Phone

Date of Birth

Email Address

City

Region/State/Province

Postal / Zip code

Emergency Contact Name

Relationship

Phone

How often do you receive massage therapy?

Are you pregnant

Yes

N/A

Please indicate your goals for your massage session.

stress management

relaxation

muscle tension release

pain management

Which heat setting are you most comfortable with?

none

low

medium

high

Enter any specific goals here.

On a scale of 1-10 what type of pressure are you comfortable with. 1 is very light 10 is very firm.

Do you have allergies or sensitivity to any oils, lotions or scents?

Which areas would you like to focus on?

Are there any areas you would like avoided?

List any current medications

List any current health conditions, major injuries, illnesses or surgeries. See chart below.

I have reviewed the cancellation policy and agree to give at least a prior 24 hour to reschedule or cancel my appointment or I will be required to pay a cancellation fee equivalent to 50% of the booked service charge. If I give less than 8 hours’ notice or don’t show up for my appointment, I will be responsible for the full service charge for my missed appointment.

I give consent to receive services from Spa Zenlae, LLC. I understand that I will be receiving a service from a licensed professional. I understand the benefits and risks of massage therapy and give my consent to receive therapy/treatment. I will notify the therapist of any questions or concerns immediately. I have provided my complete and accurate health history and will inform the therapist of any changes. I understand that draping will always be used for privacy and warmth. I assume full responsibility for services rendered and release the licensed massage therapist and Spa Zenlae, LLC from any liabilities or damages. I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever.

Your Signature

Today's Date

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A Peaceful, Private space to Relax & Rejuvenate.

Call or Text
(813)255-3988

Massage Intake

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Hours by Appointment
Monday 9am-2pm
Tuesday 9am-2pm
Thursday 9am-2pm
Friday 9am -2pm
Saturday 9am-4pm

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A Peaceful, Private space to Relax & Rejuvenate.

Call or Text (813)255-3988

Massage Intake

Call or Text
(813)255-3988