Please fill out the form below prior to your session.

General Info

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Who referred you?

Doctor & Medical Information

Are you currently under a physician’s care for any condition? (Yes/No — If yes, please explain)

Please list all current medications (including supplements) that could affect your session:

Please list any injuries, surgeries, or medical conditions (past or present):

Do you have any allergies or skin sensitivities?

Pregnancy

Are you currently pregnant? (Yes/No — If yes, how far along?)

IF you are pregnant, do you have a provider overseeing your pregnancy? (Yes/No. If yes, please indicate who your provider is and their contact number)

Are you considered a high risk pregnancy ? Yes / No (I will need clearance from your doctor for any service)

Massage / Yomassage / Yoga Preferences

Please describe any chronic pain, tension patterns, or mobility limitations.

What are your main goals for today’s session? (Relaxation, pain relief, improved flexibility, stress management, emotional release, etc.)

Preferred session pressure:

Preferred focus areas:

Areas you’d like avoided:

What are your main goals for today’s session? (Relaxation, pain relief, improved flexibility, stress management, emotional release, etc.)

Are there any sensations, positions, or movements that make you uncomfortable physically or emotionally

Have you received massage before? (Yes/No)

Yes

Have you been a part of a group Yomassage (including 2,3 or 4 people) or 1:1 Yomassage session before?

Yes

Have you taken a yoga class before?

Yes

Nervous System and Comfort

Are there specific practices or accommodations that help you feel safe and comfortable during bodywork?

Is there anything you’d like me to know about your emotional state, stress levels, or wellness journey so I can best support you?

Consent, Liability & Policies

By signing below, I acknowledge that I have read and understand this Consent, Liability Waiver, and Policy Agreement. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I consent to receive massage therapy, participate in a yoga class with UNIFY Health and Living, and/or YoMassage under the terms described above.

Click the link below to read the document.

UNIFY Health and Living Consent, Liability Waiver, & Policies

Signature

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Date

Month

Day

Year