Please provide the following contact information:

First Name	*	Last Name	*
Street Address		City	*
State	*	Zip
Home Phone		Work Phone
		Cell
E-mail	*

Your Date of Birth:  *

Occupation: 

Referred by:  *
                    (How you heard about me: i.e. Website, chat room, word of mouth, etc)

Marital Status:*

Single
Single (Divorced)
Married (to female)
  Committed Relationship (to male)

Spouse/Significant other's name: 

Height:  *

Weight:  *

Have you ever experienced a professional massage or bodywork session before?*

Yes      No

I am comfortable with being undraped during the session:*

Yes   No

Are there any medical, blood, or infectious skin conditions that I should be aware of? (including STDs, HIV, etc)

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The following section refers to your likes and dislikes in general and can be modified for each session, but they give me a general idea of what you enjoy and are looking for.

Areas you enjoy having worked the most:

Areas to avoid or that you don't like having touched:

Pressure:*      Light
                    Medium
                    Heavy
    

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)

Restraint

I am comfortable with having my genital /groin areas touched during the tantric portion of the session:*
Please see my web site to find out more about tantric bodywork

Yes      No

I am interested in having my prostate manipulated (either manually or with a prostate manipulation tool):*
Please see my web site to find out how to properly prepare for prostate work

Yes No

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Additional comments or requests:

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.

By checking yes, I agree to the above paragraph and will be scheduling an appointment for a bodywork session in the near future:*

Yes      No