Client Intake Form

    
   

Please fill out this form as completely and accurately as possible. It is better to provide too much information than not enough. All information provided on this form, as well as any provided during sessions, will be held in confidence.

* indicates a required field.

  
 

 

 
 
First Name*:

 
 
Last Name*:
  
 
Street Address *:
  
 

City*:

 State*: Zip*:  
 
Preferred Telephone (used to contact you about appointments) *:
  
 
Preferred E-mail Address*:
  
 
Date of Birth:
  
 
Referred by:

 
 
Emergency Contact:
 Relationship:  
 
Emergency Contact Phone:
  
 
What would you like to gain from massage? (e.g., relieve discomfort, relax, reduce stress)
  
 
Do you have any current physical discomforts? If yes, please describe, including location of discomfort.

 
 
Have you ever experienced any serious injury, trauma, hospitalization or surgery? If yes, please describe.
  
 
Are you currently under the care of a medical practitioner? If yes, please describe.

 
  For women:  Are you pregnant, or, is there a possibility that you might be
pregnant?		 Yes No  
 
Please list any prescriptions, over the counter, herbal preparations, vitamins or supplements you are taking and why.
  
 
What areas would you like to focus on in the massage session?
  
  What areas would you like to avoid in the massage session?  
  Have you received professional massage in the past? Yes No  
  Do you have any questions or concerns about massage? If yes, please list.  
   

CONSENT FOR MASSAGE AND DISCLAIMER

By submitting this information, I agree that:

  • The above information is true and accurate to the best of my knowledge.
  • I have stated all my known medical conditions. I will inform my practitioner of any change in my health status.
  • I acknowledge that massage is not a substitute for medical care, medical examination, or medical diagnosis.
  • Practitioner will end session in case of sexual innuendo or advances from client.
  • It is my choice to receive massage. I am aware of the benefits and risks, and I give my consent for massage.

You will be asked to sign this form when you come in for your massage.

Thank you.