INTRODUCING

Thai Massage Sacred Bodywork Client Intake Form

To schedule a session, please complete the form below. * denotes required fields.

First Name*
Last Name*
Address*
City*
State*
Zip Code*
Work No.
Home No.
Cell No.
E-mail*
Date of Birth (mm/dd/yy)*
Select Gender* Female Male
Profession*
Number of Children*
Current Physical Problems*
Previous Physical Problems*
Surgeries*
Medications
Type of Physical Activity Done*
Frequency of Physical Activity*
Have you had a Thai Massage before? * Yes No
How did you hear about Ananda's Thai Yoga Massage?*
Session times*
Hot Compress Yes No


Session dates. (List some dates and times that will work for you).*



Comments or Questions



I understand that the courtesy of 48 hours notice to cancel or reschedule my appointment is appreciated. Failure to comply will result in the full charge - no exceptions.*


 


© Thai Massage Sacred Bodywork. All rights reserved.

 

 
Thai Massage
Sacred Bodywork

PO Box 231532
New York, NY 10023
ananda@thaimassagesacredbodywork.com




It's a Stretch!
Thai massage is getting more patients off the table.

August 30, 2004 TIME article featuring Ananda doing Thai massage.

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