Dumfries Massage Spa Wellness Form

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Thank you for choosing Dumfries Massage Spa. For added convenience we now have an electronic intake form that can be filled out before your appointment. Thank you for taking the time to improve your wellness and we look forward to working with you.

Email *

Last Name *

First Name *

Address *

City/State/Zip *

Primary Phone *

Occupation *

Your Birthday *

YYYY

Have you ever received a professional massage? *

Yes

Required

When was your last massage?

Would you like to receive promotions and birthday gifts via email? *

Yes

Required

How did you learn about our location

About your massage session.

What do you want to accomplish from your massage session? *

Your preferred pressure? *

Check the areas you DO NOT wish to have massaged. *

Back

Gluteal Region

Legs

Feet

Arms

Pectoral Region

Neck

Scalp

Face

Abdomen

None. The massage therapist has permission to work on all appropriate areas.

Other:

Required

Please check any that apply *

Allergies

Blood Clots

Blood Pressure Conditions

Diabetes

Fibromyalgia

Headaches

Heat Sensitivity

Heart Problems

History of Strokes

Infections

Insomnia

Immune System Deficiencies

Lupus

Medications

Pain, Numbness, Tingling

Skin Conditions (Bruising, Acne, Rash)

Surgeries

Varicose Veins

Pregnancy

Cancer

None

Other:

Required

If you checked any of the above please explain. (Pregnancy, please state if you are high risk and how far along you are. Congratulations!)

Please read the paragraph and sign your full name.

Thank you for choosing Dumfries Massage Spa. Our therapists adhere to the NCBTMB Code of Conduct to ensure a safe, professional, and therapeutic environment for our patrons and therapists. Male/female genitalia and women’s breasts will not be exposed or massaged at any time. Draping will be used during the session to ensure your comfort. At any time during the session if you feel uncomfortable, you may ask your therapist to end the session. At any time during the session if your therapist feels uncomfortable, they have the right to end the session and refuse future services. Using the document provided, you were asked to provide our therapist’s with any pre-existing conditions and limitations, or specific areas you do not want worked on. If any of your pre-existing conditions, limitations and specific areas you do not want worked on are not noted, you assume liability for any bodily, mental and economical loss resulting from injuries sustained from your massage or spa treatment. You understand, acknowledge, and voluntarily accept the risk associated with massage and spa services while at Dumfries Massage Spa. The undersigned acknowledges she/he has read the disclaimer and has filled out the necessary paperwork to the best of their knowledge.

You acknowledge the above paragraph, please sign and date. *

Send me a copy of my responses.

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