Massage Intake FormInterested in booking a massage? Please fill out our massage intake form below, and we will be in touch shortly! Name * First Name Last Name Phone (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation Emergency Contact * Relationship Phone (###) ### #### How did you hear about us? Referral Social Media Online Search Other Medical Information Are you taking any medications? Yes No If yes, please list name and use: Are you currently pregnant? Yes No If yes, how far along? Any high risk factors? Do you suffer from chronic pain? Yes No If yes, please explain What makes it better? What makes it worse? Have you had any orthopedic injuries? Yes No If yes, please list: Please indicate any of the following that apply to you. Cancer Headaches/Migraines Arthritis Diabetes Joint Replacement(s) High/Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains Explain any conditions you have marked above: Massage Information Have you had a professional massage before? Yes No What type of massage are you seeking? Relaxation Therapeutic/Deep Tissue Cupping Other What pressure do you prefer? Light Medium Deep Do you have any allergies or sensitivities?☐ Yes No If so, please explain Are there any areas (feet, face, abdomen, etc.) you do not want massaged? Yes No If so, please explain What are your goals for this treatment session? By signing below you agree to the following. It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. Any illicit or sexually suggestive comments or actions made by me will result in immediate termination of the session and I am responsible for full payment. Client Signature * Date * MM DD YYYY Therapist Signature Date MM DD YYYY Thank you!
