Intake | Bhakti Massage

Limited availability beginning February 2021

Patrick Stockstill, Esalen® Massage teacher and practitioner

Client Intake and Consent

Name

Date of Birth

Gender/Pronouns

Email

Phone

Check any that currently apply to you

blood clots

infection

congestive heart failure

contagious disease

edema

Emergency Contact

What brings you in for massage? Please list and prioritize areas of concern

Are there any areas of your body you prefer not to have touched? (Scalp, face, feet, abdomen, etc.)

Would you recommend us to your friends?

Yes

No

Anything else you would like to add?

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Address

Contact

11100 San Pablo Ave. #211

El Cerrito, CA 94530

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