Contact Information:

First Name
Last Name
Phone
E-mail

Please describe yourself:

Age
Sex	Male Female
Height
Weight

I would like to schedule the following session:

1 Hour Swedish Massage
1.5 Hour Swedish Massage
2 Hour Swedish Massage
1 Hour BeCuddled Session
1.5 Hour BeCuddled Session
2 Hour BeCuddled Session
Group Massage Party
Pleasure Shop

I would like to schedule my session for the following date and time:

I would like my breasts massaged (Females only):

Not sure/I will decide later
Yes
No

I found your website by (select all that apply):

Your site appeared in a Google search result
Your site appeared in a MSN search result
Your site appeared in a Yahoo search result
Found link on MassageAustin.Net
Found link on other website
Saw your profile on Yahoo
Referred personally by someone
Other

Please select all that applies to you:

I have received many massages/body work in the past
I have never had a massage
I have skin irritations and/or allergies
I have arthritis and/or joint disorders
I have high blood pressure and/or heart problems
I have varicose veins and/or blood clots
I have spinal problems
I have frequent headaches
I am currently under a doctor's care
I am pregnant
I have had recent injuries and/or broken bones
I have had recent surgery

Do you smoke?

No
Yes

Do you drink alcohol?

No
Socially
Daily

List any medical condition(s) I should be aware of prior to the session:

Areas of complaint, pain, and/or tension:

What kind of work do you do?

What do you do to develop yourself spiritually?

How do you hope to benefit from my service?

What else would you like me to know before I schedule I session with you?

Special Requests:

AGREEMENT: By submitting this form, I acknowledge with my signature the following: 1) I have read the description of the massage I am requesting and understand the techniques of the specific massage modality that I am requesting. 2) If I do not want any portion of my body massaged, I have indicated those areas in the "special requests" box or will convey at time of the session. 3) If I am uncomfortable for any reason, I may ask for the massage to cease and the therapist will end the massage immediately. 4) Draping will be used unless you request no draping at time of session. 5) I have listed all of my medical conditions on this form and will update the masseuse prior to a massage should any new conditions arise.

Yes
No