Massage Intake Form

Please submit this intake form prior to your first visit.
A verbal intake will be done in the future using this form as a reference.

General Information

Name:	- Required
Email:	- Required
Date of Birth:
Address:
Phone:
Occupation:

Desired appointment:

How long of a session do you want?
60 minutes	75 minutes	90 minutes

Are you redeeming a gift certificate? Yes No

Will this be your first professional massage? Yes No

If no, are you massaged regularly? Yes No

Blaizing Lotus now offers revitalizing spa therapy!
CLICK HERE to add a spa treatment to your session.

Personal Preferences

Massage I prefer:

Pressure I prefer:

Music I Prefer:

Drape I prefer Full (sheet) Partial (hand towel)

I prefer Coconut Oil Unscented Oil Unscented Cream

Each massage includes aromatherapy.
CLICK HERE to choose aromas for this session

Health and Medical

I am allergic or sensitive to fragrances or skin care products such as: Coconut or other nut oils, scented candles/incense, essential oils, etc.
Please list:

I am currently taking medication.
Please list:

I am currently seeing a health care professional.
Please list:

I am pregnant. Months:

Do you have any of the following today:

	skin rash
	cold/flu
	sunburn

	severe pain
	open cuts
	ticklish areas

	injuries/bruises
	numbness
	anything contagious

Please explain, along with any other conditions that may be of concern:

Do you tend to get cold or hot easily? Cold Hot Neither

Check the areas you would like me to put more focus on (if any):

Check the areas you would like me to avoid (if any):

Extras

How did you hear about Blaizing Lotus?
What is your intention for this session?
Qualities I look for in a massage therapist:
Questions, comments or suggestions:

Terms and Conditions

* All massages are draped, following a professional code of conduct & ethics.
* Sexual remarks or advances will terminate the session with client liable for payment of the scheduled treatment.
* I will inform my therapist of any changes in my medical status.
* I will inform my therapist if I need the pressure to be adjusted, or experience any pain or discomfort during my massage.
* I will inform my therapist ahead of time if I have to cancel, or plan on being more than 15 minutes early or late to my scheduled appointment.
* All of the information submitted here is held confidentially, and is not stored on our server nor is it ever shared with third parties.

By checking this box, I certify that I am the above named person, that the above information is accurate, that I agree to the above terms and conditions and I understand that because massage should not be done under certain medical conditions, I have answered all questions pertaining to medical conditions truthfully. - Required

Insert above code before submitting: - Required

~ The ROSE ~

	Swedish Massage aromatherapy hot foot bath mineral heat lamp dry skin brushing
($100 for 60 minute massage and $120 for 90 minute massage)

~ The LILY ~

	Deep Tissue Massage aromatherapy hot peppermint towels body scrub mud wrap or seaweed wrap paraffin bath chocolate facial mask
($120 for 60 minute massage and $170 for 90 minute massage)

~ The LOTUS ~

	Hot Stones Massage aromatherapy body scrub mud wrap or seaweed wrap paraffin bath chocolate facial mask facial steamer hot foot bath far infrared sauna
($200 for 60 minute massage and $220 for 90 minute massage.)

~ Hot Mint Towels ~

Hot Peppermint Towels
Hand towels are heated in a crock pot, infused with a refreshing essential oil blend of peppermint, rosemary, eucalyptus, and wintergreen, and then placed on all areas of your body. The minty steam assists in clearing sinuses.

The heat from the towels loosens tight muscles, and the peppermint is an anti-inflammatory which has a nice cooling effect. This provides soothing relief for swollen, burning or achy muscles.
($10)

~ Chocolate Facial Mask ~

Chocolate Facial Mask
(Great for DRY Skin)
Cocoa powder, which is what chocolate is made of, is a wonderful and powerful antioxidant. It protects, tightens, and moisturizes the skin, while eliminating the free radicals that cause significant damage to skin layers. Chocolate has also been known stabilize moods by initiating serotonin release!

This sweet, delectable facial mask is a peaceful experience that will leave your skin soft and glowing. Other ingredients include heavy cream, ground oatmeal, honey, & avocado oil. This treatment is followed by a "faerie-made" facial elixir.
($10)

~ Strawberry/Lemon Mask ~

chocolate face mask Strawberry/Lemon Facial Mask
(Great for OILY Skin)
Lemons and strawberries are both powerful antioxidants that stimulate collogen production in the skin. The salicylic acid found in strawberries gently and effectively removes dead and dry skin cells, while reducing facial redness and swelling. The enzymes present in lemons assist in cleansing and toning the skin, while eliminating excess oils on the face.

This homeade mask is a refreshing experience that will leave your skin feeling cleansed and balanced. Other ingedients include plain yogurt and honey. This treatment is followed by a lemon & witch hazel facial toner.
($10)

*Not recommended for people with sensitive skin.*

~ Mineral Heat Lamp ~

Mineral Heat Lamp
The TDP FIM Energizer Floor Lamp is coated with a unique mineral formation consisting of over 33 elements essential to the human body. When the curing plate is heated to a certain temperature, it penetrates the minerals into your body for an absorption of up to 3 inches! The absorbed energy promotes microcirculation, metabolism, and a stronger immune system.

These lamps have been used worldwide to treat millions of patients with various chronic ailments. In China, people refer to this lamp as the "Miracle Lamp" due to its incredible success in treating chronic ailments.
($5)

~ Dry Skin Brushing ~

Dry Skin Brushing
A simple technique involving long, sweeping strokes towards the heart is used to improve the surface circulation on the skin, while opening and cleansing the pores.

Dead cells and oils are scrubbed from the skin's surface, encouraging your body's discharge of metabolic wastes and improving your ability to combat bacteria. This results in a stronger immune system, increased energy, higher metabolism, and healthier, softer, and more resilient skin. Includes a take home brush!
($20)

~ Seaweed Wrap ~

Seaweed Body Wrap
This procedure is similar to the mud wrap, only instead using seaweed clay mixed with kelp powder.

Seaweed absorbs many great minerals from the ocean. Our body's composition is similar to seawater, so seaweed is a very compatible product for our skin!

Along with being deeply relaxing, a seaweed wrap can stimulate circulation, rid the body of toxins, relieve aches and pains, tighten the skin, and leave an overall smooth and supple feeling.
($40)

~ Facial Steamer ~

Facial Steamer
Steam causes the skin to perspire, allowing pores to open up and breathe. Dirt, oil and grime, which can easily clog the pores and lead to breakouts, blackheads and other imperfections, are deeply cleansed as the steam penetrates the face.

Steam also revives tired skin, removes toxins and improves circulation. Though primarily used as a skin care technique, the facial steam is equally beneficial in relieving stress and cold symptoms.

Essential oil of your choice can be added to enhance your experience!
($5)

~ Paraffin Bath ~

Paraffin Bath
Parafin reduces pain and stiffness around joints by removing excess fluid from surrounding tissue while providing lubrication. Since paraffin is extremely heavy in molecular weight, it increases the blood supply to the area being treated and traps moisture from underlying layers of the skin, resulting in rejuvenated and nourished skin.

This treatment can be done on the hands as well as the feet! I use a soothing, anti-inflammatory wintergreen paraffin.
($10 for hands, $10 for feet)

*Paraffin treatments are not recommended for people with the following conditions: Hypertension, diabetes, & varicose veins.*

~ Sauna ~

Far Infrared Sauna
The radiant heat emitted in a far infrared sauna surrounds you and penetrates deeply into your joints, muscles and tissues, speeding oxygen flow and increasing circulation. Detoxification occurs at the cellular level, removing waste and harmful toxins such as cholesterol, mercury, lead, aluminum, and other heavy metals.

Infrared heating is also beneficial for weight loss, pore cleansing, relaxation, faster healing, stronger immune system, lower blood pressure, and pain reduction, just to name a few!
($20)

~ Mud Wrap ~

Mud Body Wrap
The mud wrap (using Fuller's Earth Cosmetic Clay) is great for softening the skin, increasing hydration, removing toxins, and promoting deep relaxation. You will be securely wrapped in several warm layers after the mud is applied.

Reiki and a scalp massage will be performed while the mud is drying. (Reiki is a Japanese "hands on" technique for stress reduction and relaxation that also promotes healing.)

After the mud is removed, it is followed with a thick, moisturizing body butter to lock in the smoothness that this body wrap gives to the skin.
($40)

~ Sugar Scrub ~

Exfoliating Body Scrub
This is a homemade product made with brown sugar as the exfoliant, combined with organic oils, aloe vera, vitamin E, and the essential oils of your choice.

The exfoliating sugar scrub is a wonderful way to open pores, eliminate dead skin cells, detoxify, increase circulation, replenish moisture, and soften the skin all at the same time.
($30)

~ Heated Foot Bath ~

Heated Foot Bath
Hot footbaths offer a wide variety of benefits to your often forgotten feet. They are great for helping to relieve rheumatic or arthritic pains, ease cramps, reduce excessive perspiration and swelling, revive tired and burning feet, and are just simply a great way to pamper your hard working feet by giving them a little extra attention!

After a good 10-15 minutes of soaking, your feet will be thoroughly dried and a good thick moisturizing cream will be applied with foot massage.
($20)

FACE RIGHT TRAP LEFT TRAP RIGHT BICEP RIGHT PEC LEFT PEC LEFT BICEP RIGHT FOREARM RIGHT AB LEFT AB LEFT FOREARM RIGHT HAND RIGHT HIP LEFT HIP LEFT HAND RIGHT QUAD LEFT QUAD RIGHT KNEE LEFT KNEE RIGHT SHIN/ANKLE LEFT SHIN/ANKLE RIGHT FOOT LEFT FOOT LEFT TRAP NECK RIGHT TRAP LEFT TRICEP LEFT SCAPULA RIGHT SCAPULA RIGHT TRICEP LEFT ELBOW LEFT LOWER BACK RIGHT LOWER BACK RIGHT ELBOW LEFT HAND LEFT GLUTE RIGHT GLUTE RIGHT HAND LEFT HAMSTRING RIGHT HAMSTRING LEFT CALF RIGHT CALF LEFT FOOT RIGHT FOOT

LAVENDER is an all time favorite! It has a sweet, balsamic, floral aroma that is balancing, soothing, normalizing, calming, relaxing, & healing. Great for soothing headaches & hangovers.

ROSE oil has a divine, rich, sweet, deep-rosy floral aroma that is healing, maternal, calming, & uplifting. Roses are associated with love, and they help to heal broken hearts & emotional stress.

JASMINE has a full, rich, honey-like sweetness that is relaxing, intoxicating, warming, & romantic. Though calming, it regulates brain waves & leads to enhanced mental functioning.

GERANIUM has a powerful, leafy-rose aroma with fruity, mint undertones. It is soothing, mood-lifting, & balancing, relieving PMS symptoms, nervous tension, & stress-related conditions.

PALMAROSA has a sweet, delicate rosey aroma that is calming yet uplifting. It clears muddled thinking, relieves stress, counters physical & nervous exhaustion, & helps release anger & grief.

LEMON relieves mental fatigue, improves mental clarity, alertness, and memory, sharpens the senses, & reduces stress. The scent is evocative of the fresh ripe peel.

LIME has a rich, cheering, freshly peeled aroma that is reviving, calming, mood uplifting, & balancing. It effectively upholds a joyful mood & cools the mind.

ORANGE has a lively, fruity, sweet aroma that is pleasant, cheering & uplifting. Refreshing but sedative, orange is a tonic for anxiety & depression.

GRAPEFRUIT has a fresh, sweet, bitter, citrus aroma. It is uplifting & cheerful and reduces stress, nervousness, & tension. It improves mental fatigue & memory retention.

TANGERINE has a very calming & soothing effect, helping you relax and improving your mood. The vibrant, citrusey fragrance of fresh tangerines is refreshing, cheerful & uplifting.

PEPPERMINT has a powerful, sweet, menthol aroma which is vitalizing, refreshing, & cooling. Helps to lessen or eliminate apathy, shock, migraines, nervous stress, vertigo & faintness.

EUCALYPTUS has a camphor-like, somewhat sweet, pine-like aroma that is purifying & invigorating. It is particularly helpful in sinus & breathing problems.

WINTERGREEN has a minty, medicinal, ice-cold aroma that is refreshing, bracing, & invigorating. It helps to relieve breathing problems, & nerve afflictions.

SPEARMINT has a refreshing, cooling, & vitalizing aroma. It energizes the mind & body, alleviates headaches & nausea, & is healing & comforting to the bereaved.

ROSEMARY has a fresh, piercing scent that is mildly pine-like but sweeter. It is clarifying & invigorating, & has an overall stimulating effect that works on both mental & physical levels.

TEA TREE has a warm, spicy, medicinal & volatile aroma. Often used as a potent antibacterial agent. It is cleansing, purifying, & uplifting. Mixes well with something minty.

PINE NEEDLE has a resinous, woodsy, holiday aroma that is refreshing & invigorating. It lightens fatigue & stress; while strengthening the respiratory tract & sinuses.

GINGER oil has a peppery, warm, spicy-woody aroma that is warming, strengthening, & anchoring. It helps boost confidence, vitality, optimism & personal drive.

CLOVE has a powerful, spicy-fruity, warm, sweet aroma that boosts immune system, facilitates memory, increases blood flow & has antidepressant & antibacterial properties.

CINNAMON has a sweet, delicate & spicey aroma that is comforting, energizing, & warming. It boosts the activity of the brain, & helps in removing nervous tension & memory loss.

NUTMEG has a warm, woody, spicy, sharp aroma that is rejuvenating, uplifting, energizing. It is used to treat stress, pain, heart disorders, indigestion, & high blood pressure.

ANISE oil has a sweet, licorice-like aroma and slight husk notes. It is cheering, mildly euphoric, & sense enhancing. It is helpful for flatulence, impotence, painful periods, migraines and colic.

ALLSPICE has a warm, spicy-sweet aroma that is warming, cheering, comforting, & nurturing. It has a calming effect on the body & the mind, & is helpful with insomnia & cramps.

CLARY SAGE oil has a spicy, hay-like, bittersweet aroma that is centering, euphoric, & visualizing. It has a calming influence on the nerves, emotions, kidneys & digestive system.

SAGE has a rich herbal aroma with a musky undertone of camphor. Stimulates mental clarity & a healthy nervous system. Helpful for people feeling nervous, anxious, & menopausal.

CEDARWOOD has a balsamic-woody aroma that evokes a feeling of inner strength & centeredness. Useful in times of emotional stress & anxiety to overcome feelings of powerlessness.

ROSEWOOD has a sweet-woody, floral-nutmeg aroma that is gently strengthening & calming. It stimulates positive, hopeful feelings; creating a state of emotional balance.

YLANG YLANG oil has a rich floral, sweet but musky, euphoric, almost narcotic aroma. It reduces stress & nervous tension, lowers blood pressure, uplifts moods, & promotes restful sleep.

FRANKINCENSE is an age old, royal resin that has a spicy, balsamic, warm and peppery aroma. It is calming, visualizing, meditative, & is highly assciated with spiritual practices.

MYRRH imparts a lush, earthy, smokey-sweet aroma that is centering, visualizing, & meditative. This sacred oil has been used to treat emotional disturbances, depression & anxiety.

PATCHOULI has a musky, earthy, rich, sweet, balsamic, woody & spicy aroma. Known for it's intensity, it is exotic, romantic, & soothing. It helps to relieve stress & overcome addictions.

LEMONGRASS has a powerful, lemony, grassy aroma that is vitalizing, balancing & cleansing. It boosts self esteem, confidence, hope & mental strength, uplifts spirit, & fights depression & anxiety.

MARJORAM has a warm, sweet-spicy & floral aroma with a hint of camphor. It calms the nervous system, clears confusion, strengthen focus, & lowers stress & anxiety.