Tell Us a Little About Yourself

Esalen® massage intake form

We take your privacy very seriously. Your personal information will never be shared with any outside party.

Your Contact Information
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Your Emergency Contact
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General Information
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*    Yes Please! *    No Thanks

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Health Questionairre
The following questions help us to address concerns and assess if you have any conditions that might be contraindicative to massage. Please check all that apply and explain if necessary.

* If so, please refer to our Contraindications page.
   
   

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Your Massage Experience

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Release of Liability

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 my 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 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.

If I make any sexual advancements or innuendos the session will be terminated immediately without a refund.

I agree to give 48-Hour notice if I choose to reschedule or cancel an appointment for any reason other than a family emergency or sudden illness. If I cancel without 48-hour notice or do not show up to my appointment I agree to pay the full cost of the massage session.

By submitting this form I affirm the accuracy of the information I have provided and understand and agree to the policies above.

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