Tammy Vaughn -> Giddings Unique Massage Therapist - Specializing in massage therapy, bodywork, full body massage, reflexology massage, swedish massage, deep tissue massage, myofascial release massage.

Intake Form

Please be complete with your answers. The more we know about you, the better service we can provide. All fields are required. Put something in the field even if a question does not apply.
 
First Name
Last Name
 
Male     Female
Date of Birth
(MM/YYYY)
Home Phone
(979) 555-1234
Cell Phone
(979) 555-1234
Email Address
Sign me up for your
E-Discount Program:*
Yes
Address
City/ST/Zip
Returning Client
Yes
Referred by:
Have you ever had any injuries (broken bones, torn ligaments, surgeries)? When?
Do you have any of the following medical conditions?
  Pregnancy Diseases Skin Disorders
Infections Blood Pressure Heart Conditions
Breathing Blood Clots Arthritis
Diabetes Cancer Elective Surgery
Other (Please Explain)
What medications are you currently taking?
Do you have any allergies or sensitivities to oils, lotions, scents or foods?
What are the appropriate areas of concern?
  Head Upper Back Knees Legs/Thighs
Neck/Shoulders Lower Back Feet/Ankles
Other (Please Explain)
Additional Comments:

Please Read: Tammy Vaughn Consent Form
By signing this consent form, I understand that Uillean Massage Therapy Center DOES NOT diagnose illness, disease or any other medical disorder. As such, Uillean Massage Therapy Center DOES NOT provide medical treatment or pharmaceuticals. I understand that any services provided are not a substitution for medical treatment and that I should see a physician for any physical ailment that I might have.

Because Uillean Massage Therapy Center must be aware of any existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep Uillean Massage Therapy Center updated on my physical health. Therefore, I assume all risk for my health and hold harmless Uillean Massage Therapy Center and Tammy Vaughn and any associated business entities, practitioners, Amenities or any persons involved in services performed.

I also understand that any illicit or sexually suggestive remarks or advances made by me at any point will result in immediate termination of the session and in this case I will be held liable for payment “In full”.

I acknowledge Uillean Massage Therapy Center maintains a 24 hours Cancellation policy. Thus, Uillean Massage Therapy Center has my authorization to keep my credit card on file in the event that I should cancel less than 24 hours prior to service date. If I choose to cancel services in less than 24 hours, I am responsible for the full amount of the service fees.

I understand that questions about service procedures and recommendations are encouraged and welcomed.


Full Legal Name
Date

Select these appointment options:
Please contact and inform me what available options I have for this week:
Please contact and inform me what available options I have for next week:
Please contact and inform me what available options I have for next month:
In most cases we will contact you back within 3 hours or by noon on the following business day.

What service(s) would you like to schedule?
  30 min (Isolated) Massage ($35)
60 min (Full Body / Isolated) Massage ($60)
90 min (Full Body / Isolated) Massage ($90)
120 min (Full Body / Isolated) Massage ($125)
60 min Hot Stone Therapy ($110)
30 min Reflexology Massage ($35)
60 min Reflexology Massage ($60)
30 min Facial Massage ($35)
60 min Facial Massage ($60)
Body Wrap ($140)
Rain Drop® Technique ($70)