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HOME
SERVICES
- MOBILE MASSAGE
FORMS
- MASSAGE INTAKE
LINKS
BLOG
MY ACCOUNT

DEREK BECTON

LMBTNC #12933

Please take a minute to complete my online intake form below. I look forward to meeting you and being of service.

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Name *

First

Last

Date Of Birth *

Gender *

Male
Female

Are you pregnant? *

Yes (If so please reschedule, prenatal massages are not done at this location.)
No
Not applicable

Email *

Phone Number *

Massage Service Location *

Office Location, Mobile Massage, or Event

Who is hosting the event? *

The person or company that planned it.

Is this a Gift Cerificate? *

No
Yes

Office Massage Service Duration *

Mobile Massage Service Duration *

Gift Certificate Service Duration *

Date and time of scheduled appointment. *

Date

Time

Event Date *

The best way to contact you. Check all that apply. *

Phone Call
Mobile Text
Email

May I contact you about Massage & Wellness Program? *

Address For Mobile Massage Service *

Address Line 1

Address Line 2

City

State

Zip Code

Occupation

Emergency Contact Name *

Emergency Contact Number *

Have you had a professional massage before? *

Medical History & Allergies (List anything that your therapist needs to be made aware of.) If there is nothing type NA. *

In order to plan a massage session that is safe and effective, I need some general information about your medical history. PLEASE EXPLAIN IN DETAIL!

PLEASE READ AND CHECK IF YOU AGREE TO THESE TERM & CONDITIONS. *

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 this 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 physician, chiropractor or other 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.

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Sign & Date Below

Today's Date *

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DEREK BECTON

LMBTNC #12933

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