Touchstone Therapy :: Massage :: Reiki :: Nutrition

{massage & reiki}

your contact information

These are the only required fields, but we encourage you to be as thorough as possible throughout the form.

First Name Last Name
Street Address
City State Zip
E-mail Address
Cell Phone
Date of Birth*

*You must be at least 18 years of age to receive massage therapy and reiki services.

How did you hear about Touchstone Therapy?

Friend/College: Name
Internet Sonic Yoga Network Wellness Care

Please Check All Current Conditions:

Allergies List:

Arthritis
Arm Pain
Cancer Type
Cold/Flu
Carpel Tunnel
Diabetes
Digestive Issues
Fibromyalgia
Headaches
Heart Disease
High Blood Pressure
Hip Pain
Hot Flashes/Menopausal Symptoms
Leg Pain
Lower Back Pain
Low Blood Pressure
Multiple Sclerosis
Neck Pain
Sciatica
Shoulder Pain
Sinus Problems
Stroke
Varicose Veins

Are you pregnant?

Yes No
If so, how many months?

Is there anything else you think I should know?

In the past, have you undergone:

Car Accident? Date
Whiplash? Date
Surgery? Date

If you have any of the following conditions, you should not get a massage.

Fever
Any type of infectious disease
Systemic infections
Severe cold
Fracture, bleeding, burns or other acute injury
Liver and kidney diseases
Blood clot
Pregnancy-induced diabetes, toxemia, preeclampsia/eclampsia
High blood pressure (unless under control with medication)
Heart disease
Cancer
Open skin lesions or sores (therapist may work around them if localized)

By clicking the “Submit” button, I acknowledge that if I have a medical condition, I have been cleared for massage by my physician. I understand that massage therapists do not diagnose illness or any physical or mental disorder nor do they prescribe any medical treatment. Massage therapy is for the well being of the body and mind. I understand that my health information will only be utilized by my therapist and everything we discuss will be kept confidential. To better the results of my massage, I have fully completed the above information to the best of my knowledge.

I also understand that massage therapy is not intended for sexual purposes. At any time during the massage should I or the therapist feel uncomfortable, the session will be terminated.

Touchstone Therapy