INTAKE FORM*

Welcome to Glow!

Please fill out the following information and press ‘Save’; the screen will automatically refresh to a blank form.

*First Name
*Last Name
*Birthday
*Email
*Mobile Phone	( ) -
*Emergency Contact Name
*Emergency Contact Phone	( ) -
*Allergies
*Is this your first massage?
*Pregnant?
*# of Caesarean Births
*# of vaginal births
*# of weeks pregnant
*Areas to avoid
*Focus areas
*Major injuries
*Pre-existing conditions

*Waiver Liability:

Glow does not diagnose illness, disease or any other medical disorder. Glow does not provide services that substitute for medical treatment. Neither Glow, its associated business entities, or its technicians assume responsibility for diagnosis treatment, which falls outside the scope of its service offerings. For medical treatment and diagnosis, guests should consult with their physician.