Confidential Client Information

I'm including this form online to save time and make it more convenient for you. If you are planning on making an appointment with me for the first time please fill out this form before your scheduled appointment time. This info is for my eyes only and will not be disclosed or shared in any way.

I ask each client to fill out a Confidential Client Information form on their first visit. The information helps me to get to know you a bit better as well as a source of information when you return for a repeat appointment. I locate the info sheet and know what pressure and preferences you like the best. I don't expect any information that will make you uncomfortable, and please know that all info given me is kept strictly confidential and I do not use it to contact you unless you ask me to. If you use any pseudonyms, then please continue to use the same one with me to avoid confusion. Normally the main method of contact is via email, so please give me an email address that is secure and private for you only.

All required fields are marked with an *. If there is a required field that you do not feel comfortable filling out, please put "****" in the field and we can discuss it when you are here.

Your First Name *
Your Last Name *
Your Street Address
Your City *
Your State *
Your Zip
Your Home Phone
Your Cell/Work Phone *
Your Email *
Date of Birth (mm/dd/yyyy) *
Your Occupation
Referral by: (person, web [which one], etc)
Marital Status *
 Single
 Single (Divorced)
 Single (Widowed)
 Married (to a female)
 Committed (to a male)
Spouse/Significant Other's Name
Height *
Weight *
Have you ever experienced a professional massage or bodywork session before? *
 Yes
 No
Please list any medical, blood, or infectious skin conditions that I should be aware of? (including STDs, HIV, etc)
Areas you generally enjoy having worked the most:
Areas to generally avoid or that you don't like having touched:
Pressure *
Type of bodywork session. Check the ONE that you are most interested in: *
 Traditional Swedish - relaxing - without release
 Taoist - sensual / relaxing - without release
 Tantric - sensual / relaxing - with release
Check any that you would possibly like to include in your session (we can talk about it first):
 Deep Tissue on the areas where I have knots
 Stretching of arms and legs
 Spanking
 Leather (let me know what aspect you are interested in)
 Restraints
 Blindfold
 Electro
I am comfortable with having my genitals / groin area worked on during the Tantric portion of the session: *
 Yes
 No
I am interested in having my prostate manipulated (either manually or with a prostate manipulation tool) *
 Yes
 No
Additional Comments or Requests
I agree to the statement below: *
 Yes
 No
 

I understand that the bodywork I receive is provided for the basic purpose of relaxation and relief of tension and stress. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and touch may be adjusted to my level of comfort. If at any point during the bodywork session I am uncomfortable with the therapist’s actions or touch, I agree to notify him immediately. Otherwise it will be assumed I am comfortable with his touch. Likewise the therapist has the right to end the session at any time he is uncomfortable with the client’s request. I understand this is a full-body session and all areas of the body will be worked unless otherwise discussed. All manipulations are for therapeutic benefits only. Because bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. I understand that charges for this and all sessions are for the practitioner’s time and not for the services or activities engaged in during the session.