Intake | Bhakti Massage

Now at the Orcas Island Healing Arts Center

Patrick Stockstill, Esalen® Massage teacher and Deep Bodywork® practitioner

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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?

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No

Anything else you would like to add?

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Address

Contact

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

info@bhaktimassage.com

360-499-3753

New client intake form

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