Barclay Massage & Wellness
Port Orange, Florida
⚠️ PHOTO ID REQUIRED: Per FL Law, a valid government ID is required for check-in.
1. Client Information
Full Name
Street Address
Phone Number
Date of Birth
Email Address
Emergency Contact
2. Health Conditions
High Blood Pressure
Diabetes
Blood Clots / DVT
Heart Condition
Arthritis
Recent Surgery
Numbness/Tingling
Easy Bruising
Allergies
Other / Medications
3. Massage Preferences
Primary Goal
-- Select Goal --
Relaxation
Pain Relief
Injury Recovery
Sports Performance
Pressure
Light
Medium
Firm
Deep Tissue
Areas of Focus
Areas to Avoid
4. Area Consent
Body Area
Yes
No
Head & Face
Neck & Shoulders
Back
Chest (Draped)
Arms & Hands
Glutes (Draped)
Legs
Feet
5. Policies & Consent
I understand cancellation/late arrival policies.
I confirm my identity and accuracy of information.
I understand massage is not medical care.
I understand mandatory draping (FL 64B7-26).
I understand inappropriate behavior results in termination.
Digital Signature
Date Signed
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