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services & rates
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book now
services & rates
our team
gift a massage
faq & policies
our friends
intake form
login
615-487-1585
2000 glen echo Rd.
suite 100
Nashville, TN 37215
If you are new to STM please complete your intake form before your appointment. Thank you!
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Indicates required field
Name
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Phone Number
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Date of birth
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Pronouns
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Email
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Preferred contact method:
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Text
Email
Right or left handed?
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Right
Left
Occupation
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Do you exercise? If yes, what do you do?
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When was your last massage?
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What brought you in today?
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Who/How were you referred?
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Emergency contact name and #
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Current medications:
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Surgeries or major injuries:
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Are any of these conditions currently or have affected your health?
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allergies
chronic pain
depression/anxiety
diabetes
dislocated clavicle/shoulder
epilepsy
headaches
heart condition
high/low blood pressure
joint replacement
lymph nodes removed
pregnancy or nursing
sensitive to oils/lotions/scents
skin condition
swelling legs/hands/feet
Are you pregnant or nursing? If YES, how far along? (we offer prenatal massage in your 2nd and 3rd trimester)
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Experiencing any of the following:
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gestational diabetes
high blood pressure
leg cramps
phlebitis
varicose veins
swollen hands and/or feet
Anything else you would like your therapist to know about your pregnancy?
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Other, please list:
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Simply Therapeutic Massage client/therapist agreement:
I understand that massage therapy is therapeutic, but it is non-diagnostic and not a replacement for care by a licensed physician. If I experience any pain or discomfort, I will immediately inform my therapist so pressure/methods can be adjusted to my comfort level. Because massage should not be performed under certain circumstances, I agree to notify the studio in writing of any changes in medical information I have provided today.
Simply Therapeutic Massage policies agreement
: I agree that Simply Therapeutic Massage has provided me with their policies and I understand that it is my responsibility to read these policies before receiving any bodywork. I agree that I have read, understand, and agree to comply with all studio policies and I consent to be legally bound by all studio policies.
I AGREE
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I AGREE
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book now
services & rates
our team
gift a massage
faq & policies
our friends
intake form
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