your body deserves more
Why and What We Do
Pricing & Plan
Thank you for visiting MassageQ.
Please Fill below form, or click PDF
and fill the questions
to help us schedule your appointment
and prepare for your visit
MT New Intake - 4.9.2019.pdf
Thank you for considering your Massage at MassageQ @ Rapha Cllinic.
Please fill out the below questions to help us schedule your appointment and prepare for your visit.
What is the Main Area, Symptons and/or Condition for your Massage?
Pain (Please Specify)
Headaches / Migraines
What is the intensity of your symptoms and current condition?
0 - 3
3 - 7
7 - 10
When was your most Recent Massage?
Less than 1 month
More than 1 month
What intensity do you want your massage pressure to be?
Light - Relaxing
Firm & Stretching not too deep
Do you have a preference with your Massage Therapist?
Female or Male
When do you want your next Massage?
Do you have a Health Insurance plan?
Yes - Please check if my plan will cover Massage and other services you offer
No - Please offer self pay rates for my future appointments
Not Interested at this time
If Yes, Upload front&back of Ins. card pics
Max File Size 15MB
Where is your Preferred Location for your Massage?
Lansdowne / Leesburg
Potomac Fall / Sterling
Arlington / Rosslyn Metro
When is your preferred days for your Massage Therapy?
Monday - Wednesday
Thursday - Friday
What is preferred time for your Massage Therapy?
11 am - 2 pm
3 pm - 8 pm
Thanks for submitting!