• New Client Intake Form

  • Format: (000) 000-0000.
  • Birthday
     / /
    2 digit month, 2 digit day, 4 digit year
  • Preferred Method of Contact*
  • Format: (000) 000-0000.

  • Massage Information

  • Have you received professional massage before and how often?*
  • What pressure do you prefer?*
  • Are you experiencing any pain or discomfort?*

  • Medical Information

  • Are you taking any medications?*
  • Are you currently pregnant?*
  • Have you received chiropractic treatment (now or in the past)?*
  • Do you suffer from chronic pain?*
  • Please indicate any of the following that apply to you now or in the past:*
  • Have you ever had any major injuries, surgeries, or car accidents?*

  • By signing below, you agree to the following.

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

  • Financial Agreement

    Payment is due at the time services are rendered. Acceptable forms of payment include cash, check, debit/credit card, and Zelle. No shows and cancellations within 24 hours of your appointment time may be subject to a fee that is 50% of the full current rate of the scheduled service. After repeat no shows/late cancellations will be charged 100% of the full current rate. 

    If you feel you may not be able to make your appointment, please contact us as soon as possible. 

  • Credit Card Authorization

    Demystify Massage requires a credit card on file. You authorize Demystify Massage to charge your card on file to process agreed upon payments for services and no-show protection. You understand that your information will be saved for future transactions on your account.

  • Consent to Massage Therapy

    It is your choice to receive massage therapy. You are aware of the benefits and risks of massage and give consent for massage. You understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. You acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. You have stated all medical conditions that you are aware of and agree to inform your practitioner of any changes in your health status. You understand that Demystify Massage has provided this form as a reference and is not held liable for any services provided.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: