Relax & Be Well

Therapeutic Massage

Preferred Method of Contact (Please choose One)*
How would you rate your overall health?*
Have you ever received a professional massage?*
Do you perform any repetitive movements in your work, hobbies, sports, ect.?*
Check all activities that apply to you*
Do you have stress in your work, family, or other aspects of your life?*
Have you had any recent accidents, injuries or surgeries (in the past 6 months)?*
Do you have any allergies/sensitivities to oils, lotions or scents? *
Do you have experience with Essential oils?*
Please check ALL that apply
Head/Neck*
Musculoskeletal System*
Circulatory System*
Nervous System*
Auto-Immune*
Respiratory System *
Skin *
Digestive System*
Psychological*
Other*
Waiver of Liability and Consent to have Massage*
Cancellation Policy*
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