Revive Modern Massage
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Date of Birth
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Have you experienced a professional massage before?
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Allergies
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Occupation
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What areas of tension would you like to focus on?
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Are you pregnant?
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What brings you in today?
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Arthritis
Osteoporosis
Recent accident / injury
Cancer
Diabetes
Neuropathy
TMJ
Carpal tunnel
Epilepsy
Fibromyalgia
Headaches / Migraines
Heart condition
Sunburn
Pacemaker
High blood pressure
Low blood pressure
Thyroid disorder
Healthy. No issues to note.
Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18. No sexual discourse or overtures of any kind will be tolerated. I understand that the massage I receive is non-sexual and 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 therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination and that I should see a qualified medical provider for any ailment that I am aware of. Because massage 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
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Revive
Services
Our Therapists
Intake Form
Finding Us
Gallery
Join the team