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Now Hiring ... REGISTERED MASSAGE THERAPISTS ... $2,000 Sign-On Bonus

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SUDBURY, ONTARIO 705.222.0043

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Starlight Suite
Nordic Lounge
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Ezentials Intake Form

First Name *

Address

Postal Code

Phone (Home) *

Last Name *

City

Occupation

Phone (Alt)

Date of Birth *

Province

Employer

Email *

Gender

Ezentials Intake Form

What is your reason for seeking massage therapy?

Have your received massage therapy in the past?

How did you hear about us?

Did a health care provider refer you for massage?

If yes, please provide their name, address, and phone number

Please indicate any preference that you generally have for massage therapy:

Therapist Gender Preference

Pressure Preference

Talking Preference

Ezentials Intake Form

Cardiovascular

Cardiovascular

High Blood Pressure

Low Blood Pressure

Congestive heart failure

Heart Attack

Varicose Veins

Pacemaker or similar device

Heart Disease

Stroke

Family History of any of the above

Respiratory

Respiratory

Chronic Cough

Shortness of breath

Bronchitis

Asthma

Emphysema

Family History of any of the above

Muscle Discomfort

Muscle Discomfort

Neck

Lower Back

Mid Back

Upper Back

Shoulders

Arms/legs

Knees

Other

Other conditions

Other conditions - other

Epilepsy

Cancer

Arthritis (or history of Arthritis)

Headaches

Herpes

Migranes

Osteoporosis

Joint replacement, pins, or wires

Other conditions - Loss of Sensation

Loss of Sensation

Please specify

Other conditions - Diabetes

Diabetes

Please specify

Other conditions - Alergies

Allergies

Please specify

Other conditions - Skin

Skin Conditions

Please specify

Other conditions - Mental

Mental illness

Please specify

Other conditions - Digestive

Digestive Conditions

Please specify

Ezentials Intake Form

Pregnant?

Due Date

If you're pregnant please specify your due date

Gynecological Consitions

General Health Status

Other Medical Conditions

Do you have any known infectious/contagious diseases at this time? if yes, what?

Current Medications and Prescribed Reasons

Surgeries / Injuries

Surgeries / Injuries Date

Primary Care Physician

Other Health Care Providers

Primary Physician - Phone

Other Health Care Providers - Phone

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Many of our services are covered under extended
health care benefits. Examples include:

Registered Massage Therapy

Naturopathic Medicine

Chiropractic Care

And more to come…

We offer everything under one roof and
make it easy for you to feel amazing.

Call Now

Call us at 705-222-0043. At Ezentials, we prefer to talk to our guests to create the best possible experience! Reception is available during all regular business hours:

Monday-Thursday ….. 9:00am-9:00pm
Friday ….. 9:00am-4:30pm
Saturday ….. 9:00am-5:30pm
Sunday ….. Closed

Call Now
Contact Info

Want to meet or talk to one of our health care providers prior to scheduling an appointment? Call and book a complimentary 15-minute meet-and-greet – available in person or by phone.

Call Us
Contact Info

Want to meet or talk to one of our health care providers prior to scheduling an appointment? Call and book a complementary 15-minute meet-and-greet – available in person or by phone.

Call Us
Contact Info