The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.Please enable JavaScript in your browser to complete this form.Name *FirstLastDate Of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender *MaleFemaleAre you pregnant? *Yes (If so please reschedule, prenatal massages are not done at this location.)NoNot applicableEmail *Phone Number *Massage Service Location *539 Keisler Dr. Ste. 203, Cary NC 27518Office LocationIs this a Groupon Gift Cerificate? *NoYesMassage Service Duration *30 Minutes45 Minutes60 Minutes75 Minutes90 MinutesGroupon Massage Service Duration *60 Minutes90 MinutesDate and time of scheduled appointment. *DateTimeThe best way to contact you. Check all that apply. *Phone CallMobile TextEmailMay I contact you about Massage & Wellness Program? *YESNOAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOccupationEmergency Contact Name *Emergency Contact Number *Have you had a professional massage before? *YESNOMedical History & Allergies (List anything that your therapist needs to be made aware of.) If there is nothing type NA. *In order to plan a massage session that is safe and effective, I need some general information about your medical history. PLEASE EXPLAIN IN DETAIL!COVID-19 Related QuestionsHave you had a fever in the last 24 hours of 100°F or above? *NOYESDo you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? *NOYESDo you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? *NOYESHave you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *NOYES Have you traveled anywhere outside of the state in the last two weeks? *NOYESIf you have traveled outside the states where? If not put NA in the box. *PLEASE READ AND CHECK IF YOU AGREE TO THESE TERM & CONDITIONS. *I understand that the massage 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 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, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists 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 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. GDPR Agreement *I consent to having this website store my submitted information so they can respond to my inquiry.Sign & Date Below *Clear SignatureToday's Date *EmailSubmit Share this:TweetWhatsAppLike this:Like Loading...