Marina Massages NYC
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About you
Name
*
Age
*
Gender
Male
Female
Email Address
*
Phone Number
*
Address
City
Zip Code
Where you referred by someone?
Your massage
Have you ever received massage therapy?
*
Yes
No
Do you have ANY of the following today?
Rated rash
Inflammation
Severe pain
Headache
Poison Ivy
Cuts
Burns
Bruises
Cold or flu
Sunburn
Check all that apply
Are there any health conditions we should be aware of? Please explain;
What are your goals for the massage?
*
Relaxation
Injury rehabilitation
High activity level maintenance massage
What type of touch do you prefer?
Light/Meditative
Heavy/Invigorating
Deep/Trigger point
How many hours per week do you participate in fisical activities or Sports?
Less than an hour
One to two hours
Three to Four hours
Five hours or more
How much water do you drink per day?
2 to 4 glasses
5 to 7 glasses
8 or more glasses
Terms & Policy
Please accept the terms before submiting this form:
*
I understand that this massage is not a replacement of a medical care and that not diagnose will be made.
Appointment cancellations policy.
*
I am responsible for paying for any appointment cancellations of less than 24 hours.
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Marina Massages NYC
