Intake Form

Name

Occupation

Date of Birth

1) How did you hear about this service?

Your Phone#

Your Email Address

3) Would you like Hot Stones?

Yes

Don’t worry, we won’t burn you like on ‘Big Mama’s House!” (This is a $10 upcharge on these packages: Soothe, Prenatal, Lymphatic. All other packages come with Hot Stones.)

4) Would you like Deep Tissue?

Yes

(This is a $10 upcharge.) (Our Fire and Ice Session comes with deep tissue for no extra charge.)

SPECIFIC INFORMATION FOR A TAILORED MASSAGE

1) Are you celebrating a special occasion?

If yes, what type?

2) What areas are aching today?

3) Would you like us to focus on a particular area today?

Yes

If yes, what?

4) Is there anything that you DO NOT like massaged? (i.e., ticklish feet, etc.)

5) Please list any condition that you have that may affect your massage

6) Have you had any recent surgeries?

If yes, what type?

Has your Dr. cleared you for massage?

7) Are you pregnant?

How many weeks?

You must be at least 13 weeks to receive a massage here.

Are you experiencing a low-risk pregnancy according to your doctor?

Has your Dr. cleared you to use the hot tub?

You must not submerge yourself for more than 10 minutes if pregnant.

TIPS: For your convenience, a mandatory gratuity of 10-15% will be added to your bill at check-out. Gratuity amount depends on session. Please leave an additional tip at check out if you enjoyed your experience. Our therapists rely on their tips, as this is a service industry.

JEWELRY: Please remove all jewelry including studs (you can leave on rings) and put them in your purse or locker.

HAIR: Please put hair up tightly in a pony tail holder, so that your therapist can massage your neck and back.

WIGS: If at all possible, please remove your wig or tie it up, as it may be in the way or may fall off during your session. Your therapist will provide you w/a basket for your clothes & personal items IF you choose to remove it.

CELL PHONES: We encourage the use of cell phones to take selfies and pictures of your elegant session here. However, your massage therapist is not allowed to start your session until your phone is put away in the basket provided

CHAIR ROOM: Please be courteous of others and keep your voices low and do not talk on your cell phones.

LATE ARRIVAL: If you arrived late, your session may have to be cut, so the next client doesn’t lose any of their time.

LOCKERS: We Are Not responsible for lost, damaged or stolen items. Please put your valuables inside of our complimentary lockers. These lockers are monitored by security cameras at all times.

Signature

Date

Submit

INTAKE FORM

HOURS OF OPERATION

OUR LOCATION

Bow Tie Massage

RESERVATION REQUEST