Asheville Massage and Spa Therapies

Spa Materna Intake Form

We want to create a very pleasant and comfortable massage experience for you. By completing the form below, you will assist us in creating the ultimate massage experience for you. The information you provide on this form will be kept private and confidential. Please complete the following form, print it out and bring it with you to your About Us.

Name:

DOB:

Address:

City:

State: Zip:

Phone:

Emergency Contact

Name:

Phone:

Relation:

Email:

Would you like to receive our newsletter? Yes No

Physicians Name:

How did you hear about Spa Materna?
Friend	Ad	Website	Other

If applicable, name of person that referred you

How many massages have you had prior to today?
None	1- 5	6 - 10	11+

Please check all symptoms that apply to you below. This information is completely confidential and important in customizing your treatment. It will only be shared with your written permission.

Column 1	Column 2
Pregnancy	Sciatica
Trying to Conceive	Skin irritation
Nursing	Open wound
Allergies	Nausea
Arthritis	Swelling
Bruise easily	Hemorrhoids
Asthma	Leg cramps
Stomach bug*	Muscle spasm
Cold-current*	Decreased flexibility
Cold-recent0	High Blood Pressure
Dislocations/Fracture	Rash/Burn
Painful Periods	Osteoporosis
Fever*	Eczema, Rosacea
Numbness or tingling	Fibromyalgia
Pulled muscle	Strain/Sprain
Back/Neck Injury	Depression
Surgery in the past year	Varicose veins
Surgery in the past 6 weeks*	Sinus pain
Migraines	Cosmetic surgery
Cancer	Lymphedema
Heart condition	Blood clots
Scoliosis	Implants
Headaches	Stroke
*Massage not recommended at this time
Are you allergic to essential oils? Yes No
Please list any medications you are currently taking along with the reason it is prescribed.

What areas would you like the massage therapist to focus on during a massage?

Are there any areas you want your therapist to avoid?

What kind of pressure do you prefer on a scale of 1 to 10?
1=Very light 10=Very firm

We strive to treat you as an individual. We want your treatment to be customized to your likes and dislikes. Is there anything else about you or your body that you want to share with us?

Your comfort and safety, are of the utmost concern at all times during your treatment. It is your responsibility to request changes in pressure, speed or any other variables in your treatment. Massage therapy is not a substitute for medical treatment. Massage therapists do not diagnose illness or disease or prescribe medication.

Please indicate your understanding of the above/below and give informed consent by initialing the statements below and signing your name.

Because therapeutic massage should not be performed under certain circumstances, I affirm that I have checked off all medical conditions of which I am aware.

I will inform my practitioner of any changes in my medical status.

I have not withheld any information that may be relevant to my treatment.

If I experience any pain or discomfort during my treatment, I will immediately inform my practitioner.

I forever release Spa Materna,LLC, its director and employees from all liability for any injury or damage which may occur as a result of the treatment rendered.

By checking this box, I certify that I am the above named person, that the above information is accurate and that I agree to the above terms and conditions.

Please print this page, then sign and date it below:
Signature: __________________________________
Date: ______________________

(828) 254-2222
Call today to schedule your appointment!