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Intake Form

Please complete the following form or click here to print & complete prior to your visit.

*Any pre-existing medical conditions may require a documented approval from your medical provider prior to your visit.
Thank you for understanding.

Massage By Machelle Intake Form

Medical Information

Massage Information

Are you taking any medcations?
Have you had a professional massage before?
Are you currently pregnant?
What pressure do you prefer?
Do you have any allergies or sensitivities?
Do you suffer from chronic pain?
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Have you had any orthopedic injuries?
FRONTNEWEST2.jpg
Please indicate FRONT RIGHT areas of pain Required
Please indicate FRONT LEFT areas of pain Required
BACKNEWEST.jpg
Please indicate BACK LEFT areas of pain Required
Please indicate BACK RIGHTareas of pain Required
LEFTRIGHTNEWEST2.jpg
Please indicate LEFT SIDE areas of pain Required
Please indicate RIGHT SIDE areas of pain Required

Thanks for submitting!

930 Bent Oak Ct
Lake St Louis, MO 63367

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(636) 579-6908

©2023 by Massage by Machelle. 

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