Kenji Massage

Name:
Email Address:
Alternate Contact Preference. Please provide phone number if desired.
Known health problems:
Current medications taken, if any:
Have you had massage before?	Yes No
Reason for massage:
I DO NOT give the therapist permission to work on the following areas of my body. Areas NOT checked will not be massaged:	Head Face Neck Shoulders Back Chest Arms Hands Abdominal Buttocks Pelvis Thighs Legs Feet
I prefer to be draped in the following manner:	Full Sheet Towel No Drape
Any additional information about you the therapist should know:
To the best of my knowledge the information I have provided is accurate and true. I understand that if at any time I am uncomfortable or experience discomfort with the massage or any technique being used, I can ask the therapist to change the technique,	Yes
Date:

Relax . Refresh . Renew