Name *

First Name

Last Name

Phone *

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Music Preference

Please check any music or sounds you would enjoy hearing for your session.

Soft Piano

Native Drumming

New Age

Celtic

White Noise

Ambient

Acoustic Guitar

Other

Favorite Scents, Oils & Lotions *

I use organic Non-Scented Coconut Oil, Bio-tone, Grape seed, Sesame or Almond oils as carrier oils. Let me know if you have allergies to any of these. I use DoTerra essential oils for those who would like to experience aromatherapy during their sessions. Please list your preferred scents to be used during your session if any. Non-scented is always an option.

On Guard (similar to thieves with cinnamon, cloves, orange etc.)

Citrus Blends

Eucalyptus Blends

Mint Family

Sage, Lavender or Floral Blends

Non-Scented

Allergy to any of these products of scents please contact me prior to our session.

18 or over / If Minor, Authorization of Guardian for the application of massage therapy. *

Please check the appropriate box

Client is a minor. As parent or legal guardian, I authorize Laura Wheeler lmt to provide massage therapy to said minor to promote wellness care.

I have fully read and understand this intake form and to the best of my ability have answered all questions truthfully for either myself or the minor of whom I have legal custody of.

Signature and Date *

By digitally signing below, you are authorizing Laura Wheeler, lmt to provide Massage Therapy to you. You are also releasing Laura Wheeler, lmt of any liability financial or else wise should and symptoms unknown or previously known be aggravated or inflamed. Massage is intended to be beneficial to the body ,mind and spirit. Although it is uncommon, there may be some brief discomfort, your massage session should not be painful. By signing this form you state that you will let Laura Wheeler, lmt know if any aspect of the massage causes discomfort or pain so that you may be properly adjusted, advised to stop pr guided according to your needs. You also state by signing this form that you have informed Laura Wheeler, lmt of any illnesses, diseases or conditions that would make this massage therapy session inappropriate for your health to your best knowledge.

First Name

Last Name

Date of Electronic Signature *

MM

DD

YYYY

Name *

First Name

Last Name

Best Phone Contact Info *

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Are you happy with your body image?

Yes

No