We Love Massage :: Deep Tissue, Craniosacral, Swedish, Chair massage, Spa Parties, Infant Massage Classes. Located in Montrose, near Glendale and Pasadena

We Love Massage
3460 Ocean View Blvd suite # B
Montrose, CA 91208
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Minutes away from Glendale, Pasadena, La Crescenta and La Cañada Flintridge

First Time Client Information Form -
Massage and CranioSacral services by We Love Massage

* required fields

Full Name:* A value is required.
Occupation:
D.O.B.:* A value is required.
Address:* A value is required.
City:* A value is required.
Zip:* A value is required. Invalid format.
Phone:* A value is required.    Cell:
Referred by:
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In case of emergency:* A value is required.
Emergency phone:* A value is required.

Please list any injury, allergy or condition you might have:

What are your massage or bodywork goals?

Please check which type of pressure you prefer?
light medium firm

Have you ever experienced a professional massage or bodywork session?
Yes No If yes, how recently?

If you answer “yes” to any of the following questions, please explain as clearly as possible.

Yes  No  Diabetes?
Yes  No  Headaches?
Yes  No  Pregnant? If so, how many weeks?
Yes  No  Arthritis?
Yes  No  Contact or dentures?
Yes  No  Epilepsy or seizures?
Yes  No  Blood pressure? Taking medication for that? Yes  No
Yes  No  Do you have any contagious diseases?
Yes  No  Do you have osteoporosis?
Yes  No  Have you been in an accident or suffered any injuries in the past two years?
Yes  No  Do you have any allergies?
Yes  No  Do you have cardiac or circulatory problems?
Yes  No  Are you very sensitive to touch or pressure in any area?
Yes  No  Have you ever had surgery? Explain below.

Yes No Do you have any other medical condition,
or are you taking any medications I should know about?

Comments:

Disclosure and Consent for massage:
I understand that the massage/bodywork I receive is provided for the basic purpose of
relaxation and relief of muscular tension. If I experience any pain or discomfort during this
session, I will immediately inform the practitioner so that the pressure and/or strokes may
be adjusted to my level of comfort. I further understand that massage or bodywork should
not be construed as a substitute for medical examination, diagnosis, or treatment and that
I should see a physician, chiropractor, or other qualified medical specialist for any mental
or physical ailment of which I am aware. I understand that massage/bodywork practitioners
are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any
physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

Cancellation: You must check this box to agree before sending the form.
Minimum 24-hour notice required or you will be responsible for full payment of the treatment scheduled.

You must check this box to agree before sending the form.
I understand that checks are not accepted. Form of payment:
in person is cash only or online with paypal prior to the session.

You must check this box to agree before sending the form.
I have read and understand the above disclosures. I have consented to use the services offered, and agree to be personally responsible for the therapist fees.

Date:

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