Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Personal Information
Layout
Full Name
*
Phone
*
Emergency Contact Name
*
Gender
*
Male
Female
Relationship
*
Single
Married
Other
Date of Birth
*
Email
*
Contact Information
*
Address
Occupation
Medical History & Lifestyle
Layout
Do you have any allergies?
*
Lavender
Coconut
Peanut
None of the Above
Other
Are you on any medication?
*
eg. Ibuprofen, Supplements,etc
Are you currently pregnant?
*
Yes
No
Smoking Habits
*
Yes
Occasionally
No
List here If not Listed
*
Medical conditions or health concerns we should be aware of?
*
eg. Diabetes, High Blood Pressure,etc
Skin Type
*
Dry Skin
Oil Skin
Combination Skin
Sensitive Skin
Not Sure
Stress Level
*
1
2
3
4
5
6
7
8
9
10
Not Sure
Do you have any of these conditions (Checkbox if you have any)
Areas of swelling
Autoimmune disorder
Back / neck problems
Bleeding disorders
Blood clots
Bruise easily
Bursitis
Cancer
Contagious condition
Decreased sensation
Diabetes
Fibromyalgia
Headaches
Heart condition
Hypertension
Kidney disease
Multiple sclerosis
Neurological condition
Neuropathy
Osteoarthritis
Osteoporosis
Phlebitis
Sciatica
Seizures
Stroke
Tendinitis
TMJ disorder
Varicose veins
Vertigo / dizziness
Layout
Areas of broken skin? (e.g. rash, wounds)
No
Yes
Where?
Recent injuries or medical procedures in the past 2 years?
No
Yes
Please describe:
History of joint replacement surgery?
No
Yes
Which joint(s) ?
Please describe any other injuries or health conditions:
Leave empty if there is none
Massage Information
Layout
Have you had professional massage before?
No
Yes
How recently?
How much pressure do you prefer?
Light
Medium
Firm
Reason for seeking massage:
Relaxation
Stress relief
Alleviate pain
Specific problem
Specify here;
Consent & Agreement
*
I have provided accurate health information and will update the spa of any changes in my health status.
I understand that spa treatments at Bareskinn Spa are for beauty and therapeutic purposes only. Any inappropriate behavior will result in immediate termination of the session.
How did you find us
*
Instagram
The web
Friend or Family
Billboard
Other
If other please state;
By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.
Signature
*
Clear Signature
Date
*
Submit
