Massage Therapy

NEW CLIENT INTAKE FORM

Please fill out the following form.

First name

Last name

Date of birth

Day

Month

Year

Email

Phone

Emergency Contact ( Name & Phone number)

Are you pregnant?

No

Yes

Any allergies? ( oils, lotions, nuts, fruits, skin, etc.)

No

Yes

If you answered yes please list

Are you taking any medications?

No

Yes

If you answered yes please list

Areas of broken skin? (e.g. rash, wounds)

No

Yes

If you answered yes please list

History of joint replacement surgery?

No

Yes

If yes, which joint(s)?

Please specific others conditions

I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment nor perform spinal manipulations. I will inform the therapist of my current condition at the time of each visit.

Initials

I declare that the info I’ve provided is accurate and complete.