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- LASH LIFTING AND TINTING
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- BODY TREATMENTS
HOLISTIC CARE
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ABOUT US

Address: 117 River Street West Springfield, MA 01089 | Email: jenna@mindbodyandskin.com

CALL US TODAY! (413) 734-7470

117 River Street West Springfield, MA 01089 jenna@mindbodyandskin.com

CALL US TODAY! (413) 734-7470

Mind Body & Skin

HOME
SKIN SERVICES
- FACIALS
- WAXING
- MAKEUP
BROWS/LASHES
- EYEBROWN SHAPING AND TINTING
- LASH LIFTING AND TINTING
BODY SERVICES
- MASSAGES
- BODY TREATMENTS
HOLISTIC CARE
- REIKI
- CELLULITE WRAP
SPA PACKAGES
ABOUT US

Confidential Client Massage Consultation

CONFIDENTIAL CLIENT MASSAGE CONSULTATION

Name:

What is the date of your scheduled appointment?

Date of Birth:

Address:

City

State

Zip

Home/Cell Phone:

Business phone:

Email:

Referred by

Have you had a professional massage before?

Yes

No

What Type?

How long have you been receiving massage therapy?

Frequency of massages?

What are your goals for today’s treatment?

Do you exercise regularly?

Yes

No

Do you perform repetitive movements in your work, or hobbies?

Yes

No

What is your level of stress?

Have you recently had a surgery, injury, or any area of inflammation?

Yes

N

Do you have any allergies? Please list

List any current medications

Conditions/Treatments/Reason for medications listed above?

Please check any condition listed below that applies to you:

contagious skin condition

osteoporosis

epilepsy

headaches/migraines

cancer

diabetes

decreased sensation

back/neck problems

Fibromyalgia

phlebitis

deep vein thrombosis/blood clots

carpal tunnel syndrome

joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis

tennis elbow

open sores or wounds

easy bruising

recent accident or injury

recent fracture

recent surgery

artificial joint

sprains/strains

current fever

swollen glands

allergies/sensitivity

heart condition

high or low blood pressure

circulatory disorder

varicose veins

atherosclerosis

TMJ

Other

Please explain any condition

Are you pregnant? if yes, how many months?

Free Text

Typing in your name below verifies that all the information on the Massage Consultation Form is understood and accurate.

Client Name:

Date:

Thank you for completing this form.

We look forward to seeing you!

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Skin Care Consultation Form

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HOME
SKIN SERVICES
- FACIALS
- WAXING
- MAKEUP
BROWS/LASHES
- EYEBROWN SHAPING AND TINTING
- LASH LIFTING AND TINTING
BODY SERVICES
- MASSAGES
- BODY TREATMENTS
HOLISTIC CARE
- REIKI
- CELLULITE WRAP
SPA PACKAGES
ABOUT US

CONTACT INFORMATION

Address: 117 River Street West Springfield, MA 01089

Phone: (413) 734-7470

Email: jenna@mindbodyandskin.com

Spa Hours

Mon, Thu: 9:00 am - 8:00 pm
Tuesday: 8:30 am - 8:30 pm
Wed, Fri: 8:30 am - 8:00 pm
Saturday: 9:00 am - 5:00 pm
Sunday: 9:00 am - 6:00 pm

Visa Payment Accepted

MasterCard Payment Accepted

Discover Payment Accepted

American Express Payment Accepted

Cash Payment Accepted

OUR LOCATION

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