Intake Form

Please enter your full name^*

Gender^*

Date of birth (DD/MM/YYYY)^*

Please enter your profession^*

Email address^*

Phone number^*

How did you hear about Kůra Růka?^*

Have you ever had a professional massage before?^*

If yes, what type of massage therapy?

If yes, how often do you receive massage therapy?^*

What type of pressure do you normally prefer?^*

Do you usually prefer music being played while you are receiving a massage? Note: If you answer ‘Yes’, your therapist Raphaël will play gentle and soothing ambient, handpan, or guqin music in the background during the therapy.^*

Do you practice a sport / physical activity?^*

If yes, which one?

Please check all that apply. I have / I had / I am / I was…^*

Please provide as much detailed information as possible about the conditions that you previously checked above.^*

Please indicate any other relevant information that might be useful to the massage therapist, such as areas of discomfort/tension that you would like Raphaël to focus on, or areas he should avoid during your session (i.e. due to past trauma).^*

By signing this form, I confirm the truthfulness of this information.^*

Sign by entering your full name below along with today’s date^*