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 Name
Emergency Contact Phone
2. Health & Structural Conditions
High Blood Pressure
Diabetes
Blood Clots / DVT
Heart Condition
Arthritis
Recent Surgery
Numbness / Tingling
Easy Bruising
Allergies
Hip Flexor / Adductor Tightness
Sciatica / Lower Back Stiffness
Shoulder / Mobility Restriction
Current Injuries, Medical History, or Medications
3. Massage & Lifestyle Preferences
Primary Goal
-- Select Goal --
Athletic Performance & Training Recovery
Pain Relief & Chronic Tension Management
Injury Rehabilitation & Mobility
Stress Relief & General Relaxation
Preferred Pressure Level
Deep Tissue
Firm
Medium
Light
Daily Activity & Lifestyle (e.g., Desk Job, Weightlifting, Manual Labor, Running)
Specific Areas of Focus / Chronic Tension
Areas to Strictly Avoid
4. Area Consent
Body Area
Yes
No
Head & Face
Neck & Shoulders
Back
Chest (Draped)
Arms & Hands
Glutes (Draped)
Legs
Feet
5. Policies & Informed Consent
I understand the cancellation, late arrival, and card-hold policies.
I confirm my identity and verify that all health information is accurate.
I understand that massage therapy is for structural recovery and is not medical care.
I understand that mandatory professional draping is maintained at all times (FL 64B7-26).
I understand that any illicit or inappropriate behavior results in immediate session termination.
Digital Signature (Type Full Name)
Date Signed
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