Zeppelin Massage, LMT | Houston TX 77006

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Zeppelin Massage Therapy, LMT
Confidential Client History

First Name:

Last Name:

Address:

City:

State:

ZIP:

Date of Birth:

Email:

Best Contact Phone:
example: 832-555-1212

Occupation:

Have you ever received a professional massage before: Yes No

How often do you receive professional massages?:

How did you hear about me:
Outsmart   Masseurfinder
Other Internet Site:
Referred By (First & Last Name):

Please check the item(s) that apply:

Cancer
Diabetes
Heart Problems
Headaches

High blood pressure
HIV
Joint Problems
Pregnancy

Recent injuries
Spinal injuries
Surgery
Vericose veins

If you checked any of the above please explain:

Are you currently under a doctor's care and/or taking any prescribed medications:

Do you have any tense or sore areas that need special attention:

What are your expectations of the massage session:

How much pressure do you like?
Light
Medium
Deep Tissue (hard)

Preferred draping:
Undraped (no clothing)
Draped

How would you like to recieve promotions and reminders?
Phone Email Text Message None

I understand that massage therapy is for the purpose of stress reduction, relief from muscular discomfort and for increasing blood, lymph and energy circulation. It is made clear to me that massage therapy is not a substitute for medical examination or diagnosis. I understand the massage therapist does not diagnose illness, disease or any other physical disorder and I release the massage therapist of all liability from injury.

The solicitation of sexual acts is a violation of state laws and is punishable by fine and / or imprisonment. Such behavior will result in immediate termination of the session and payment in full will be required. If a massage is to be rescheduled you will need to give the massage therapist 4 hours notice before canceling.

PLEASE ENTER YOUR INITIALS TO AFFIRM THE ABOVE PARAGRAPH:

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