Illuminate Touch Intake Form

Name*

First NameLast Name

Date of Birth*

Please select your date of birth

Gender*

MaleFemale

Occupation*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact*

Please enter a valid phone number.

How did you hear about us?

Other

Promo Code

Are you taking any medications?*

If yes, please list in next field.

Please list medications (If none, type N/A)*

Are you currently pregnant? *

How far along?

Any high risk factors? (If none, type N/A)*

Do you suffer from chronic pain? *

Please explain your chronic pain. What makes it better? What makes it worse?

Do you currently have any injuries? *

List injuries

Have you recently undergone surgery?*

Please list type and date of surgery

Have you received clearance from your physician to receive massage therapy?*

Please list Physician's name below

Please indicate any of these conditions that apply to you:*

Have you had a professional massage before?*

What type of massage are you seeking?*

Other

What pressure do you prefer?*

LightMediumDeep

Do you have any allergies or sensitivities? *

Please explain

Are there any areas you DO NOT want massaged?*

Please list

Client Agreement

I understand that the massage therapy is intended to enhance
relaxation, reduce pain caused by muscle tension, increase range of motion, improve
circulation and offer a positive experience of touch. Any other intended purposes for
massage therapy are specified below:
The general benefits of massage, possible massage contraindications and the
treatment procedure have been explained to me. I understand that massage therapy
is not a substitute for medical treatment or medications, and that it is recommended
that I concurrently work with my Primary Caregiver for any condition I may have. I am
aware that the massage therapist does not diagnose illness or disease, does not
prescribe medications, and that spinal manipulations are not part of massage therapy.
I have informed the massage therapist of all my known physical conditions, medical
conditions and medications, and I will keep the massage therapist updated on any
changes. I understand that there shall be no liability on the practitioner’s part due to
my forgetting to relay any pertinent information.
If I experience any pain or discomfort during the session, I will immediately
communicate that to the therapist so the treatment can be adjusted.
I understand and agree to abide by the therapist’s polices and will not hold Illuminate Touch LLC or the therapist responsible for any personal injury or loss of property.

I have completed this form to the best of my ability, and I agree to inform my therapist if any of the above information changes.

Print Name*

Signature*

Please verify that you are human*

NEW CLIENT INTAKE FORM FOR MASSAGE THERAPY SERVICES

MEDICAL INFORMATION

MASSAGE INFORMATION