Simply Relaxed Massage Therapy Client Intake

New Client Questionnaire & Consent Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Full Name *

First Name Last Name

Birth Date

Month Day Year

Phone Number *

E-mail *

How did you hear about us?

Referred by

Have you had a professional massage before?

Do you have any difficulty lying on your front, back, or side?

Please explain

List any allergies/ sensitivities

Is there a specific area of the body where you are experiencing tension, pain or discomfort?

Any recent illness, injuries, surgeries or ongoing health issues?

Are you pregnant?

*How far along?

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. Any inappropriate behavior will not be tolerated and session will end .

If I experience any pain or discomfort during my session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage therapists are not qualified to diagnose, adjust, prescribe or treat any disease or illness and that a massage should not be a replacement for medical treatment.

The massage I receive is voluntary and I release Simply Relaxed and/or Masseuse from liability and assume full responsibility thereof.

Signature *

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Date