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Zeppelin Massage Therapy, LMT
Confidential Client History
First Name:
 Last Name:
Address:
City:
 State:
 ZIP:
Date of Birth:
    		Email:
Home Phone:
 example: 832-555-1212		 Work phone:
 example: 713-555-1212
Mobile Phone:
 example: 281-555-1212		 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   Houston Voice   Masseurfinder  
Other Internet Site:  
Referred By:  
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  Draped 
If draped, covered with Sheet  Towel 
How would you like to recieve promotions and reminders?
  Phone   Email   Mail   Text Message  

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: