New Client Intake Form

Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Birth Date

MonthDayYear
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's name blanks
Physician's phone # Area Code Phone Number
Emergency contact name *
Emergency contact relationship *
Emergency contact phone # Area Code* Phone Number*
Have you had a professional massage before?*

YesNo

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 implied or stated 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.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.
Signature

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Health Information