Debra J. Macking, Licensed Massage Therapist


The below information is required to be filled out and sent via e-mail prior to your first massage. Copy and paste the information into a .doc/.rtf/.txt file or simply into the body of an e-mail and send it to achievinglife@gmail.com with subject: MassageClient Standard Intake Form. We are in the process of creating a form to send your responses via the site Note that at the appointment you will be verifying information. NAME: ______________________________________ ADDRESS: ___________________________________ PHONE #:____________ ALT. PH #: ____________ DATE OF BIRTH: __________ LIST ANY INJURIES OR SURGERIES YOU HAVE HAD IN THE LAST 12 MONTHS: ____________________________________________________________ PLEASE CHECK ANY MEDICAL CONDITIONS YOU HAVE THAT ARE LISTED BELOW: ____Arthritis ____Contact Lenses ____Whiplash ____Pregnant ____Cancer ____Diabetes ____Heart Problems or Stroke ____Varicose Veins ____Skin Infections ____ Other, Please Specifiy: ______________________________________________ Do you smoke? _____ How often? ______ Do you drink alcohol? ____ How often? ______ How much water do you drink on average each day? _________ What areas are you experiencing discomfort? _________________ Have you had massage therapy before? _________ When?________________________ Where did you hear about us? _______________________________ About Your Massage: Your massage therapist has been trained here in the state of Florida and is a Licensed Massage Therapist. During the massage you will be draped with a sheet. At any time during the massage either you or the therapist may stop the session. Please alert the therapist if the pressure of the massage is too much or not enough also inform the therapist of any areas that you prefer not to have worked. Areas that will NOT be worked on either male or female clients, is the genitalia, by requesting that this area be worked is wrong and grounds for the massage to end at that time with full payment still due. I HAVE READ THE ABOVE SATEMENT AND AGREE TO ABIDE BY IT and HAVE COMPLETED THE ABOVE FORM TO THE BEST OF MY ABILITY. ____________________________________________________ Client Signature and Date
~ Thank You ~ Always remember: Live, Love, Laugh, and Learn! Site Design by David Michaels and Debra J. Macking. Copyright © 2008. All rights reserved. Achieving Life Hand Logo © 1998 Walter Ramsey. Used with permission.

The below information is required to be filled out
and sent via e-mail prior to your first massage.
Copy and paste the information into a .doc/.rtf/.txt file
or simply into the body of an e-mail and send it to
achievinglife@gmail.com
with subject: MassageClient Standard Intake Form.
**We are in the process of creating a form to send your responses via the site** Note that at the appointment you will be verifying information.

NAME: ______________________________________

ADDRESS: ___________________________________

PHONE #:____________
ALT. PH #: ____________
DATE OF BIRTH: __________

LIST ANY INJURIES OR SURGERIES YOU HAVE HAD IN THE LAST 12 MONTHS: ____________________________________________________________

PLEASE CHECK ANY MEDICAL CONDITIONS YOU HAVE THAT ARE LISTED BELOW:

____Arthritis
____Contact Lenses
____Whiplash
____Pregnant
____Cancer
____Diabetes
____Heart Problems or Stroke
____Varicose Veins
____Skin Infections
____ Other, Please Specifiy: ______________________________________________

Do you smoke? _____ How often? ______

Do you drink alcohol? ____ How often? ______

How much water do you drink on average each day? _________

What areas are you experiencing discomfort? _________________

Have you had massage therapy before? _________
When?________________________

Where did you hear about us? _______________________________

About Your Massage:

Your massage therapist has been trained here in the state of Florida and is a Licensed Massage Therapist.
During the massage you will be draped with a sheet. At any time during the massage either you or the therapist may stop the session.
Please alert the therapist if the pressure of the massage is too much or not enough also inform the therapist of any areas that you prefer not to have worked. Areas that will NOT be worked on either male or female clients, is the genitalia, by requesting that this area be worked is wrong and grounds for the massage to end at that time with full payment still due.

I HAVE READ THE ABOVE SATEMENT AND AGREE TO ABIDE BY IT and HAVE COMPLETED THE ABOVE FORM TO THE BEST OF MY ABILITY.

____________________________________________________
Client Signature and Date

~ Thank You ~
Always remember: Live, Love, Laugh, and Learn!