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REQUEST AN APPOINTMENT
SPECIALS
- Monthly Specials
- Passport Program
Massage
Skincare
- Customized Facials
- Waxing Services
GIFT CERTIFICATES
Policies
MASSAGE INTAKE FORM
GALLERY
La Tourelle Hotel
The Bistro at La Tourelle

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Massage Intake Form

Want to save time at check in? Please take a moment to fill out our intake form online.
Be sure to have each individual having services with us fill out a separate form and submit it.

MASSAGE INTAKE FORM

* Indicates required field

Name *

First

Last

Cell Phone *

Email *

Residential zipcode *

DATE AND TIME OF YOUR CURRENT APPOINTMENT *

Is this your first massage? *

Yes No

Do you have a pressure preference for your service today? *

Light Medium Firm

Are you currently under the care of a physician? If so please explain *

PLEASE LIST ANY ALLERGIES WE SHOULD BE AWARE OF *

Do you have any of the following conditions? *

Pregnant or Nursing Heart Condition Vericose Veins Diabetes Metal plates or pins Epilepsy None Applicable

Some services are contraindicated for certain conditions. We need to know ahead of time if we will need to adjust or change your treatment protocol

Are you currently on any of the following medications: *

Muscle Relaxants Pain Medication Antihypertensives Diuretics Blood Thinners None Applicable

PLEASE LIST ANY PAIN, INJURIES OR AREAS OF FOCUS YOU WOULD LIKE ADDRESSED DURING YOUR MASSAGE TODAY *

DO YOU HAVE ANY SPECIFIC TREATMENT GOALS FOR YOUR SESSION TODAY? *

Submit

AUGUST MOON SPA... WHERE RELAXATION BEGINS

CONTACT & LOCATION SITEMAP

AUGUST MOON SPA AT LA TOURELLE
1150 Danby Road (96B) • Ithaca, NY 14850
(607) 256-2772

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REQUEST AN APPOINTMENT
SPECIALS
- Monthly Specials
- Passport Program
Massage
Skincare
- Customized Facials
- Waxing Services
GIFT CERTIFICATES
Policies
MASSAGE INTAKE FORM
GALLERY
La Tourelle Hotel
The Bistro at La Tourelle

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