Every Mother Deserves One!
Call Us Today: 406-212-8088

Schedule A Massage

If this is your first time, please fill-in the following form to help me provide you with the best massage treatment possible. If you have previously filled out this form, simply follow the link on your left to check availability and schedule massage or give me a call at 406-212-7225. Morning massages must be scheduled the night before.

Visit our About Us page to find out more information or fees, payments, what to expect and cancellations.

Name (Last, First, MI)
Age/Sex

Requested Time/Date/Special
Address (Street, City, ST, Zip)
Email
Home Phone

Cell Phone
Occupation
Emergency Contact Name

Emergency Contact Phone
Referred By
Have you had massages, bodywork/treatments before? Yes

No
Are you sensitive to smells? Yes

No
Do you have any allergies? Yes

No
Are you currently under a physician’s care? Yes

No
Are you taking any blood-clotting medication? Yes

No
Are you taking any blood-thinning medication? Yes

No
Are you taking any sensation-altering medication? Yes

No
Do you have a tendency to bruise easily? Yes

No
Have you recently been exposed to a communicable disease? Yes

No
Do you have any recent injuries? Yes

No
If so, please explain:
Please list the areas you wish to focus on/reason for your visit
Please list the areas you wish not to have focused on

Please check any of the following medical conditions/symptoms that you have experienced in the last year

Heart Disease
High Blood Pressure
Hospitalization
Hepatitis
Carpel Tunnel
Sciatica
Stroke
Varicose Veins

Surgery
Herpes Simplex
Whiplash
Asthma
Angina
Phlebitis/Thrombosis
Fibromyalgia
Disc Problems

Immunity Related Disorder
Insomnia
Hypertension
Migraines
Contagious Disease
Pregnancy
Repetitive Strain Injury
Other: Please describe



Please read and sign
I verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential.

I hereby give my consent to receive massage services and/or other bodywork or treatment.

Client Signature*

Date*

Massage Client Waiver Form
Please take a moment to read and initial the following information:

I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation.*

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.*

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.*

I affirm that I have notified my therapist of all known medical conditions and injuries.*

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapists part should I forget to do so.*

I understand that massage is entirely therapeutic and non-sexual in nature.*

By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy.*
Client Name*
Client Signature*

Date*

If you have trouble submitting this form – feel free to print and bring along to your appointment to save some time.