top of page

Patrick Stockstill, Esalen® Massage Teacher and Practitioner

About
Book a Massage
Couples Massage Retreat
Massage Classes
Gift Card
More

Use tab to navigate through the menu items.

Client Intake and Consent

Name

Date of Birth

Gender/Pronouns

Email

Phone

Emergency Contact

Check any that currently apply to you

blood clots

infection

congestive heart failure

contagious disease

edema

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?

Thanks for submitting!

Office

Contact

Healing Arts Center
453 North Beach Rd.
Eastsound, WA 98245

info@bhaktimassage.com

510-846-2797 (m)

New client intake form

©2017-2024 by Bhakti Massage | Esalen® is a registered trademark of Esalen Institute

Licensing

WA MA.61150888

CAMTC # 16854

NCBTMB Provider #1000343

member ABMP

bottom of page